Satisfaction Survey

Today's Date *

Name of staff responsible for service: *

Service Provided: *

Description of Service: *

Has this program helped you to resolve your questions, concerns or problems?

Did the staff appear to have the knowledge needed to assist you?

Is the staff polite & helpful?

Does the staff respect your ideas and choice?

Does the staff provide information & services being offered by OTHER agencies?

Are you usually able to reach the staff within a few days?

Were you given the name(s) of the person(s) to contact if you have questions or concerns about this program?

Is the program staff responsive to any questions or concerns you have raised about this program?

How would you rate the overall quality of this program?

Were services rendered and explained in a way that you could understand?

Are there any excellent features of this program?

If so, what are they?

How could this program be improved?

Additional comments about this program:

Would you refer a family member or friend?