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* 1. Program Visited

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* 2. Was this your first time visiting us for this type of service?

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* 3. Were you treated in a friendly and respectful manner?

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* 4. Did you receive the services, product, or help you needed today?

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* 5. If not did you receive guidance to help find the services?

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* 6. What were the services you wanted or needed that we could not provide?

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* 7. Was the cost of the service an issue for you?

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* 8. Were your questions answered?

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* 9. What did we do well?

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* 10. What can we do to improve our services?

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* 11. Services/Program

  Yes No N/A
Easy to find in building
Comfortable waiting room
Appropriate waiting time
Appointment time met your needs

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* 12. Employees Staff

  Yes No N/A
Knowledgeable about program
Professional attitude
Professional appearance
Friendly/Polite
Helpful

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* 13. How did you hear about us?

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* 14. How did you receive this survey?

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