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* 1. Enter Today's Date:

Date

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* 2. What is the reason for your most recent contact with the Scott County Veterans Office?

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* 3. I am currently:

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* 4. How did you find out about services at the Scott County Veterans Office?

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* 5. What is your most recent service era?

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* 6. Currently, what is your biggest concern or challenge?

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* 7. Check the services you have utilized in the last year.

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* 8. To what extent do you agree or disagree with the following statements?

  Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
The Scott County Veterans Office staff was able to answer my questions and/or respond to my concerns.
I would recommend the Scott County Veterans Office to another veteran.
I was satisfied with the service I received during my most recent contact with the Scott County Veterans Office.
The Scott County Veterans Office has had an impact on my quality of life.

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* 9. Please provide any additional feedback or comments about the Scott County Veterans Office. (Optional)

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