* 1. My Age:

* 2. I am a:

* 3. My race/ethnicity is:

* 4. Indicate the category which best describes you:

* 5. Number of years interacting with this agency:

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

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

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

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

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

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

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

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

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

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

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

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

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