* 1. Date of service(s):

* 2. Location of service(s):

* 3. Services that you received today (select all that apply):

* 4. Please rate the items below:

  Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
The office hours and appointment times met my needs.
The information provided was clear and easy to understand.
The staff was friendly and polite.
The staff was well informed.
The staff was helpful.
I was served in a timely manner.
The services I received met my cultural and/or special needs.
The building was clean and comfortable.
I am completely satisfied with today's services.

* 5. Please leave your name, address, phone number or email address if you would like us to respond to your comments.

* 6. Please feel free to leave any additional comments on what we did well or what we could do better.