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* 1. Date of Service:

Date

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* 2. What is your zip code? 

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* 3. Where did you receive MCDBOH services or information?

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* 4. What program or service did you receive from us?

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* 5. I was treated with courtesy and respect by the staff who helped me today?

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* 6. Staff were professional, knowledgeable, and competent?

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* 7. Services and information were received in a timely and efficient manner?

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* 8. I am pleased with the customer service I received today?

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* 9. How did you find out about our services?

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* 10. Gender

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* 11. How old are you?

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* 12. What is your race / ethnicity?

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* 13. What language(s) do you speak at home?

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* 14. Additional Comments, Questions, Concerns (What can we do to make your experience better?):

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