Name:                                                   

Address:                                                                      

E-mail Address:                                                         Phone number:

We want to express our comments about: (please use a separate sheet or back for additional comments.)

 

For each item identified below, circle the number to the right that best fits your judgment of its quality.
Use the scale above to select the quality number.

Description/Identification of Survey Item

Scale

Poor 

Good

Excellent

1.      Communication response time

1

2

3

4

5

2.      Person responsible for my case answered my questions

1

2

3

4

5

3.      Staff seemed knowledgeable about our situation

1

2

3

4

5

4.      Would recommend this agency to others

1

2

3

4

5

5.      Availability of representative

1

2

3

4

5

6.      Chance that we would use the agency again

1

2

3

4

5

Area we were most happy with:

Suggestions for improvement: