Customer Complaint Form
Boone County Health Department - Belvidere, IL

Formulario de quejas del Cliente
Departamento de Salud del Condado de Boone - Belvidere, IL

We're sorry that you did not have a favorable experience with us.

Thank you for taking the time to give us your feedback.

Lamentamos que no haiga tenido una experiencia favorable con nosotros.
Gracias por tomarse el tiempo de hacernos llegar sus comentarios.

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* 1. Describe what happened. / Describa lo que paso.

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* 2. Where did this happen? / Donde paso esto?

Logan Ave. Office. / En la Oficina localizada en la Ave Logan.

Mobile Health Unit. / En la Unidad Movil.

Other (please specify). / Otro (especifique por favor)

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* 3. When did this happen? / Cuando paso esto?

Date / Fecha

Date

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* 4. Suggestions? / Sugerencias?

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* 5. Would you like us to follow-up with you? / Quiere que le hagamos un seguimiento?

We will respond with an update on complaints within five business days if follow-up is requested. / Le contestaremos con una actualización de las quejas en un plazo de cinco días laborables si se solicita un seguimiento.

If you don't give us contact information and ask for follow-up, we will not be able to follow-up with you. / Si no nos proporciona información de contacto y solicita un seguimiento, no podremos ponernos en contacto con usted.

Yes, by email (be sure you include your email in question #8). / Si, por correo electronico (favor de asegurarse que incluya su correo electronico en la pregunta #8).

Yes, by phone (be sure you include your phone number in question #10). / Si, por telefono (favor de asegurarse que incluya su numero de telefono en la pregunta #10).

Customer Complaint Form
Boone County Health Department - Belvidere, IL

Formulario de quejas del Cliente
Departamento de Salud del Condado de Boone - Belvidere, IL

Question Title

* 1. Describe what happened. / Describa lo que paso.

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* 2. Where did this happen? / Donde paso esto?

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* 3. When did this happen? / Cuando paso esto?

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* 4. Suggestions? / Sugerencias?

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* 6. First Name / Primer Nombre

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* 7. Last Name / Apellido

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* 8. Email Address / Correo Electronico

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* 9. Confirm Email / Confirme el Correo Electronico

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* 10. Phone Number / Numero de Telefono

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* 11. Confirm Phone Number / Confirme el numero de Telefono

Customer Complaint FormBoone County Health Department - Belvidere, ILFormulario de quejas del ClienteDepartamento de Salud del Condado de Boone - Belvidere, IL

Question Title

* 1. Describe what happened. / Describa lo que paso.

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* 2. Where did this happen? / Donde paso esto?

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* 3. When did this happen? / Cuando paso esto?

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* 4. Suggestions? / Sugerencias?

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* 6. First Name / Primer Nombre

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* 7. Last Name / Apellido

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* 8. Email Address / Correo Electronico

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* 9. Confirm Email / Confirme el Correo Electronico

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* 10. Phone Number / Numero de Telefono

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* 11. Confirm Phone Number / Confirme el numero de Telefono

Customer Complaint Form
Boone County Health Department - Belvidere, IL

Formulario de quejas del Cliente
Departamento de Salud del Condado de Boone - Belvidere, IL