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* 1. Date of Visit

Date

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* 2. Were you greeted promptly by front office staff?

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* 3. Did you feel welcome and respected in the reception area?

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* 4. Did you have an appointment?

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* 5. If yes, were you seen within 10 minutes of your appointment time?

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* 6. Did the case worker treat you with respect?

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* 7. Was the case worker knowledgeable?

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* 8. Did you receive assistance on the day you were seen?

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* 9. If no, why not?

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* 10. Comments/How can we better serve you?

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