Customer Satisfaction Survey FY12Customer Satisfaction Survey FY12

Thank you for taking the time to complete this short customer service survey.

1. Date

	MM		DD		YYYY
Survey Date	Date Survey Date Month	/	Day	/	Year

2. Please choose the Region Ten office location where you most recently visited:

Please choose the Region Ten office location where you most recently visited:

Other (please specify)

3. How would you rate the following?

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree	N/A
Staff are courteous.	*How would you rate the following? Staff are courteous. Strongly Agree	Staff are courteous. Agree	Staff are courteous. Neutral	Staff are courteous. Disagree	Staff are courteous. Strongly Disagree	Staff are courteous. N/A
Staff are helpful.	Staff are helpful. Strongly Agree	Staff are helpful. Agree	Staff are helpful. Neutral	Staff are helpful. Disagree	Staff are helpful. Strongly Disagree	Staff are helpful. N/A
Staff are professional.	Staff are professional. Strongly Agree	Staff are professional. Agree	Staff are professional. Neutral	Staff are professional. Disagree	Staff are professional. Strongly Disagree	Staff are professional. N/A
Staff return my phone calls.	Staff return my phone calls. Strongly Agree	Staff return my phone calls. Agree	Staff return my phone calls. Neutral	Staff return my phone calls. Disagree	Staff return my phone calls. Strongly Disagree	Staff return my phone calls. N/A
I am treated with respect.	I am treated with respect. Strongly Agree	I am treated with respect. Agree	I am treated with respect. Neutral	I am treated with respect. Disagree	I am treated with respect. Strongly Disagree	I am treated with respect. N/A
The atmosphere is welcoming.	The atmosphere is welcoming. Strongly Agree	The atmosphere is welcoming. Agree	The atmosphere is welcoming. Neutral	The atmosphere is welcoming. Disagree	The atmosphere is welcoming. Strongly Disagree	The atmosphere is welcoming. N/A
I was attended to promptly.	I was attended to promptly. Strongly Agree	I was attended to promptly. Agree	I was attended to promptly. Neutral	I was attended to promptly. Disagree	I was attended to promptly. Strongly Disagree	I was attended to promptly. N/A
The waiting area was pleasant.	The waiting area was pleasant. Strongly Agree	The waiting area was pleasant. Agree	The waiting area was pleasant. Neutral	The waiting area was pleasant. Disagree	The waiting area was pleasant. Strongly Disagree	The waiting area was pleasant. N/A
This location is convenient.	This location is convenient. Strongly Agree	This location is convenient. Agree	This location is convenient. Neutral	This location is convenient. Disagree	This location is convenient. Strongly Disagree	This location is convenient. N/A
This location is clean.	This location is clean. Strongly Agree	This location is clean. Agree	This location is clean. Neutral	This location is clean. Disagree	This location is clean. Strongly Disagree	This location is clean. N/A

4. How many times have you had contact with Region Ten staff in the past 12 months?

How many times have you had contact with Region Ten staff in the past 12 months? Once

2 - 5

5 or more

5. How long have you been involved with Region Ten?

How long have you been involved with Region Ten? 1 year or less

2 - 3 years

4 - 6 years

more than 6 years

6. Which customer type would you consider yourself? (mark only one)

Which customer type would you consider yourself? (mark only one) Consumer	Family Member	Friend of Consumer	Community-Based Organization
Other (please specify)