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.

Today's date:

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* 1. Today's date:

MM/DD/YYYY
Your race/ethnicity:

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* 2. Your race/ethnicity:

What is your age group?

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* 3. What is your age group?

What is your gender?

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* 4. What is your gender?

How are you related to the children?

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* 5. How are you related to the children?

Are the children living:

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* 6. Are the children living:

T