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1. Date of Service:

Date
Time

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2. Name of the site location you visited:

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3. Please check all of the programs and services you used today:

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4. Were you satisfied with the program services you received?

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5. Did a staff member offer you any additional services today?

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6. Did a particular staff member help you today, that you would like to mention by name?

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7. The Community Action Site I visited is safe:

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8. The Community Center I visited is well-maintained:

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9. The Community Action staff were courteous and professional:

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10. I would recommend Community Action programs/services to others:

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11. (Optional) What is your gender?

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12. (Optional) What is your racial/ethnic background?

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13. Thank you so much for taking the time to help us improve! Please leave us any additional questions or comments in the textbox below.

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14. If you would like us to contact you about the service you received, please leave us your name and a good way to contact you: