Survey

2012 Children Services Customer Survey

We want to know your opinion about our services. Please complete the on-line survey and follow the instructions to submit your answers directly to the Quality Improvement Department. The information you provide is confidential. We appreciate your input.

1. Today's date:

	MM		DD		YYYY
MM/DD/YYYY	Today's date: MM/DD/YYYY Month	/	Day	/	Year

2. Your race/ethnicity:

Your race/ethnicity: Caucasian/white

African-American/black

Asian/Pacific Islander

Hispanic/Latino

Native American

Other

Other (please specify)

3. What is your age group?

What is your age group? under 18

18-30

31-45

46-60

over 60

4. What is your gender?

What is your gender? Male

Female

5. How are you related to the children?

How are you related to the children? Mother

Father

Relative

Non-relative/Caregiver

Other (please specify)

6. Are the children living:

Are the children living: In your home

Out of your home

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