CUSTOMER SATISFACTION SURVEY

Thank you for taking time to complete our survey. Your feedback is important to us. Please note, all responses are confidential and will not impact your program eligibility or benefits.
Which employee assisted you?
Please list the employees name in "Other" section below, if they are not listed in the drop down menu.
Date of visit

MonthDayYear
How did you hear about us?
Which center did you visit?
Other:
Please list the employees name here, if not listed in drop down menu above.
Which service(s) did you receive upon your visit? Select all that apply.

Other
How would you rate the performance and knowledge of our staff members?

Were they helpful?
How would you rate the timeliness and efficiency of your recent visit?

Were the services you needed easy to access? Did you have to wait long to access those services?
Overall Satisfaction

Did our services and staff meet your expectations?
Please share any comments or concerns about your experience:
Should be Empty:

Thank you for taking time to complete our survey. Your feedback is important to us. Please note, all responses are confidential and will not impact your program eligibility or benefits.