Health Department (Customer Satisfaction Survey)

Customer Satisfaction Survey

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* 1. Agency you visited:

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* 2. Please tell us when you visited the program

Date

Date

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* 3. Overall, how satisfied are you with the customer service you received?

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

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* 4. Please rate our customer service on the following attributes:

	Very Satisfied	Satisfied	Neutral	Dissatisfied	Very Dissatisfied
Friendly & Courteous	Friendly & Courteous Very Satisfied	Friendly & Courteous Satisfied	Friendly & Courteous Neutral	Friendly & Courteous Dissatisfied	Friendly & Courteous Very Dissatisfied
Timely & Responsive	Timely & Responsive Very Satisfied	Timely & Responsive Satisfied	Timely & Responsive Neutral	Timely & Responsive Dissatisfied	Timely & Responsive Very Dissatisfied
Accurate & Consistent	Accurate & Consistent Very Satisfied	Accurate & Consistent Satisfied	Accurate & Consistent Neutral	Accurate & Consistent Dissatisfied	Accurate & Consistent Very Dissatisfied
Accessible & Convenient	Accessible & Convenient Very Satisfied	Accessible & Convenient Satisfied	Accessible & Convenient Neutral	Accessible & Convenient Dissatisfied	Accessible & Convenient Very Dissatisfied
Truthful & Transparent	Truthful & Transparent Very Satisfied	Truthful & Transparent Satisfied	Truthful & Transparent Neutral	Truthful & Transparent Dissatisfied	Truthful & Transparent Very Dissatisfied

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* 5. What was the reason for your visit?

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* 6. Suggestions or Comments about our service:

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* 7. Your feedback is anonymous.
However, if you would like us to respond to your feedback, please leave your contact information below.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number