Please answer the questions below about your visit. Your answers will help us continue to improve our customer service. 1. How do you feel about your recent experience with us? a. I was served in a timely manner. Strongly Disagree Disagree Not Sure Agree Strongly Agree b. My needs were understood. Strongly Disagree Disagree Not Sure Agree Strongly Agree c. I was treated with respect Strongly Disagree Disagree Not Sure Agree Strongly Agree d. Overall, I was satisfied with the service I received. Strongly Disagree Disagree Not Sure Agree Strongly Agree 2. Did you need language interpretation or Sign language help? No (Go to Question 3) Yes (Go to Question 2a) 2a. Did you get it? No (Go to Question 3) Yes 2b. Were you satisfied with it? No (Go to Question 3) Yes 3. Any comments /suggestions: 4. For us to know who we can better serve, we'd like to know something about you. What is your gender? Male Female Prefer Not To Say Other What is your age? Under 17 18-34 35-54 55-65 Over 65 What is your ethnicity? Hispanic Not Hispanic or Latino What is your race? Asian Indian Korean WHITE Chinese Vietnamese BLACK Filipino Other (please specify below) Other race What zip code do you live in? Submit
