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* 1. Facility Name:

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* 2. Are you a....

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* 3. What is your primary language?

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* 4. Do you know about the Ombudsman services that are available to you?

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* 5. How did you hear about the Ombudsman Program?

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* 6. Have you ever filed a complaint with the Ombudsman?

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* 7. Please answer the following....

  Yes No Not Sure NA
Was your complaint responded to in a timely manner?
Was the program representative knowledgeable?
Was your complaint handled in a professional manner?
Do you feel that your privacy was respected?

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* 8. Are you satisfied with the results to your complaint?

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* 9. If you were dissatisfied, WHY?

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* 10. Will you call the Ombudsman if you need help again?

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* 11. If your answer to the above question is No, tell us why...

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* 12. How can we improve the Ombudsman Program?

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