* 1. Date of visit to Community Action Center?

Date / Time

* 2. What kind of help did you NEED from CAC when you visited? (For example, Utility Assistance, Emergency Food, Section 8 help, Weatherization, etc.)

* 3. I received services, information, or a referral that helped my situation.

* 4. What kind of help did you receive from CAC, if any?

* 5. The staff person helped me understand the program/services & guidelines.

* 6. If CAC could not provide the help you needed, the staff person helped with a referral for services elsewhere.

* 7. I was informed of other services offered at Community Action Center.

* 8. If there are no services/referrals for the need you have, please list unmet need(s) below:

* 9. On a scale of 1 to 10, how would you rate your overall experience with Community Action Center?

* 10. Do you have any other feedback or comments you would like to share about your experience with Community Action Center?