Client Satisfaction Survey FY 2010

Thank you for contacting us!
Please take a moment to complete this survey about your most recent experience with the Chapter. Please rate each question on a scale of 1-5 with 1= very poor and 5= very good. Your comments help us provide the highest level of service to our callers.

1. Date

	MM		DD		YYYY
Date of contact with the National Multiple Sclerosis Society, New Jersey Metro Chapter	Date Date of contact with the National Multiple Sclerosis Society, New Jersey Metro Chapter Month	/	Day	/	Year

2. Communication

	Very Poor	Poor	Fair	Good	Very Good
Promptness of response to your phone call or email	Communication Promptness of response to your phone call or email Very Poor	Poor	Fair	Good	Very Good

3. Communication

	Very Poor	Poor	Fair	Good	Very Good
How well staff member listened to your requests	Communication How well staff member listened to your requests Very Poor	Poor	Fair	Good	Very Good

4. Communication

	Very Poor	Poor	Fair	Good	Very Good
Courtesy of the person who answered your call	Communication Courtesy of the person who answered your call Very Poor	Poor	Fair	Good	Very Good

5. Communication

	Very Poor	Poor	Fair	Good	Very Good
Staff member's sensitivity to your needs	Communication Staff member's sensitivity to your needs Very Poor	Poor	Fair	Good	Very Good

6. Communication

	Very Poor	Poor	Fair	Good	Very Good
Degree to which staff member communicated the information clearly	Communication Degree to which staff member communicated the information clearly Very Poor	Poor	Fair	Good	Very Good

7. Communication

	Very Poor	Poor	Fair	Good	Very Good
How well your questions were answered	Communication How well your questions were answered Very Poor	Poor	Fair	Good	Very Good

8. Communication

	Very Poor	Poor	Fair	Good	Very Good
Degree to which you were encouraged to call back for additional information and/ or service	Communication Degree to which you were encouraged to call back for additional information and/ or service Very Poor	Poor	Fair	Good	Very Good

9. Service

	Very Poor	Poor	Fair	Good	Very Good
Likelihood of using this Information and Refferal Service again	Service Likelihood of using this Information and Refferal Service again Very Poor	Poor	Fair	Good	Very Good

10. Service

	Very Poor	Poor	Fair	Good	Very Good
Likelihood of recommending this service to someone else coping with MS	Service Likelihood of recommending this service to someone else coping with MS Very Poor	Poor	Fair	Good	Very Good

11. Additional Comments or Requests

Additional Comments or Requests

12. If you would like to be on our mailing list, please complete the information below.

If you would like to be on our mailing list, please complete the information below. Name:
Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

13. Please tell us, are you:

Please tell us, are you: Person with MS

Spouse of a person with MS

Child of a peron with MS

Family member of a person with MS

1. Client Satisfaction Survey