Tell us about your experience!

GOOD IS NOT GOOD ENOUGH.

Please take a few moments to let us know how we did today, and what we can do to improve service for the community.

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* 1. Which site did you visit?

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* 3. How did you schedule your appointment?

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* 4. Please tell us if you agree or disagree with the following statements

  Strongly disagree Disagree Unsure Agree Strongly agree
The Energy Assistance representative explained the application process and benefits.
The site I visited was convenient, clean, and pleasant.
I believe the information I received by the call center, website, and/or flyer helped me prepare for my appointment.
Overall, I believe I received great service from the Milwaukee County Energy Assistance program.

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* 5. Is there something more/better/different we could have done to improve your experience with Milwaukee County Energy Assistance?

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* 6. If you would like, could you please share your name and contact information with us?

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* 7. We always enjoy sharing stories about how Milwaukee County Energy Assistance can help families.  If you have a story about how we helped you and your family, please share it with us!  (We promise not to identify you by more than your first name and city/neighborhood.)

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* 8. If you shared a story with us, could you also share a picture of yourself? It helps us share stories about the work we do! (We promise not to identify you by more than your first name and city/neighborhood.)  If not, that's okay, just go to the next item!

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By submitting a story and/or photograph, I grant permission to Milwaukee County Department of Health and Human Services and its agents or employees to use photographs and/or text submissions submitted by me, and I know I have all necessary rights and permissions to do so for the materials I have submitted. These images may be used in educational and documentary materials such as Public Service Announcements, Grant Applications, Video Documentaries and both printed and online newsletters and the like. Furthermore, I authorize the use of my image, likeness, and words for all program promotion, materials, and any other purposes in connection with the program deemed appropriate and necessary by the Milwaukee County Department of Health and Human Services.

I hereby agree to release, defend, and hold harmless Milwaukee County Department of Health and Human Services and its agents or employees, including any firm publishing the finished product in whole or in part, whether on paper, via electronic media, or web sites, from any claim, damages, or liability arising from or related to the use of the photographs/words, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution.

I am 18 years of age or older and have read this release before checking the box below indicating my understanding and agreement, fully understanding the contents, meaning, and impact of this release. i understand that checking the below box and submitting this survey and data will be interpreted as a free and knowledgeable acceptance of the terms of this release.

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* 9. Do you understand and agree to the above?

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