Survey | Qualtrics Survey Software

As a public service agency, we appreciate the opportunity to serve the community and in an effort to improve our service delivery, please rate the service you received either today or in the past and offer any ideas you might have to help us serve you and the community better.

Gender

Male
Female

Please check one of the following:
I am a ….

Staff member
Customer receiving services
Parent of a child receiving services
Foster/adoptive parent or applicant
Service provider (i.e. counselor, mentor, trainer, etc.)
Visitor
Other (fill in the blank below)

Please check one of the following:
I met with …..

Administrative Staff Member
Caseworker
Supervisor
Manager
Other (fill in the blank below)

Please place a check in the block that best reflects your opinion.

Please place a check in the block that best reflects your opinion.
			Yes	No
Did you receive prompt service?
Were you treated courteously and respectfully?
Was the process explained in a way you understood?
Did you feel that your ideas were considered?
Were you offered resources to assist you and your family?
Did you leave with the assistance you requested?

How would you rate your overall experiences?

Excellent	Good	Fair	Poor

(If you answered no in any area, would you be willing to be contacted so that we can serve you better?)

Name
Phone Number