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* 1. Today's Date:

Date / Time

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* 2. How did you hear about QCAP? Check all that apply.

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* 3. Did you visit QCAP's website? Check all that apply.

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* 4. Which QCAP program helped you? Check all that apply.

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* 5. Was the program staff professional and courteous?

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* 6. Did QCAP staff provide you with information about other programs?

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* 7. Was the material and information helpful and clear?

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* 8. Would you recommend QCAP to a friend or family?

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* 9. Does your primary language make it difficult to use QCAP services?

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* 10. Your feedback is very important to us. Do you have any additional comments you would like to share?

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* 11. Input Survey Number Below. (For Internal Use Only)

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