E-Mail
What was the date or the approximate date of your agency contact?
What type of contact?
Please choose one
Office
Phone
Other
If "Other" Please Specify
What brought you to office?
Please Choose One
New Application
Re-Application
Job Search
Other
If "Other" Please Specify
Which department did you see?
Please Choose One
Medicaid, Food Stamp, Cash
Assistance
One-Stop Job & Training Services
Child Care
Child Support
Children Services
Did you have a scheduled appointment?
Please Choose One
Yes
No
How long did you wait?
Please Choose One
Less Than 5 Minutes
5 to 15 Minutes
More Than 15 Minutes
Was there any service you expected that you did not receive?
Please Choose One
Yes
No
If "Yes" Please Specify
Where you treated courteously?
Please Choose One
Yes
No
If "No" Please Specify
Did the agency assist you in finding services elsewhere if we could not help?
Please Choose One
Yes
No
If "No" Please Specify
Were your questions answered?
Please Choose One
Yes
no
If "No" Please Specify
Were your telephone calls returned?
Please Choose One
Yes
No
If "No" Please Specify
In general how do you feel about the services provided by this agency?
Please Choose One
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisdied
Please Comment on Your Answer
Other comments
If you would like to be contacted about this survey, please provide your name and preferred method of contact;
e.g. phone number, e-mail or mailing address.
Name
Phone
Mailing Address