Head Start Application Satisfaction Survey

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* 1. Date of Application Interview:

Ex: MM/DD/YYYY

Date

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* 2. Location of Application Interview:

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* 3. Person who assisted me with the Interview:

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* 4. Overall, how satisfied or dissatisfied were you with your experience?

If Dissatisfied, please let us know why:

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* 5. How responsive was staff to your questions and/or your concerns?

If Not Responsive, please let us know why:

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* 6. Was NHA Staff professional and courteous?

Yes

No

If No, please explain:

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* 7. Was everything clearly explained?

Yes

No

If No, please explain:

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* 8. We would appreciate your suggestions for improvement and/or any comments, questions or concerns.

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* 9. Would you like to receive a telephone call from NHA management to further discuss your Application experience? If YES, please share your name, the best telephone number and time of day to call.

My Name:

Phone #:

Best Time: