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* 1. My Age:

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* 2. I am a:

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* 3. My race/ethnicity is:

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* 4. Indicate the category which best describes you:

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* 5. Number of years interacting with this agency:

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* 6. Times in contact with this agency in the last 12 months:

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* 7. The facility was clean, orderly and accessible.

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* 8. Staff members were knowledgeable, helpful and readily identified themselves.

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* 9. The web site was easy to use and well organized.

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* 10. The web site contained clear and accurate information on events, services and contact information.

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* 11. My telephone call, e-mail or letter inquiry was routed to the proper person.

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* 12. My telephone call, letter or e-mail inquiry was answered in a reasonable amount of time.

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* 13. Printed brochures or written material provided thorough and accurate information.

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* 14. My inquiry to the agency was addressed in a reasonable manner.

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* 15. This organization makes it easy to give suggestions or to make a complaint.

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* 16. Overall, I am satisfied with my experience.

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* 17. Help Us Serve You Better: Please provide additional comments on staff performance, agency services, and/or suggested improvements.

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