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* 1. Thank you for taking a moment to share your feedback. Your input helps us improve our services and better support our community. This quick survey should take just 2–3 minutes to complete.
*Contact information is optional (remain anonymous).
**Contact information is needed to be entered into the monthly prize drawing. However it is not necessary for providing feedback.

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* 2. County of Residence (required):

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* 3. Please select the Community Action Agency you’d like to share feedback about (required):

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* 4. For each question, please select one of the following:
5 – Very Satisfied
4 – Satisfied
3 – Neutral/Uncertain
2 – Dissatisfied
1 – Very Dissatisfied

  Very Satisfied Satisfied Neutral/Uncertain Dissatisfied Very Dissatisfied
How satisfied were you with the welcome you received upon arrival?
How satisfied were you with the courtesy and professionalism of the staff?
How satisfied were you with how well staff listened to and understood your needs?
How satisfied were you with the explanation of available services and next steps?
How satisfied were you with the timeliness of the service you received?
How satisfied were you with the quality of the services provided?
How satisfied are you with the support and resources the agency provided to help you work toward your personal and/or family goals?
How satisfied are you overall with your experience at this agency?

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* 5. If you’d like, you may mention the name of any staff member(s) who assisted you during your interaction with the Community Action Agency.
*You can leave this blank if you prefer not to list any names, or if you do not recall any names.

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* 6. What is one thing we could do to improve your experience? (optional)

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