I would like to rate (please specify name of service, staff, department, etc. that you are rating):

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* 1. I would like to rate (please specify name of service, staff, department, etc. that you are rating):

Based on my experience last (please specify date you availed service, met staff, etc.):

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* 2. Based on my experience last (please specify date you availed service, met staff, etc.):

Date and time of survey (please specify date and time today):

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* 3. Date and time of survey (please specify date and time today):

My rating is:

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* 4. My rating is:

What I liked most:

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* 5. What I liked most:

What I disliked most:

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* 6. What I disliked most:

Suggestions:

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* 7. Suggestions:

I am an

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* 8. I am an

Thank you for helping us to improve. If you would like us to get back to you regarding your concerns, please indicate your details below. Thank you.

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* 9. Thank you for helping us to improve. If you would like us to get back to you regarding your concerns, please indicate your details below. Thank you.

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