* 1. Today's Date:

Date / Time

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

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

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

* 5. Was the program staff professional and courteous?

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

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

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

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

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

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