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* 1. What activity area/benefit are you evaluating ?

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* 2. Overall, how satisfied are you with the service you received.

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* 3. Please rate us on the following items

  Excellent Good Average  Poor Very Poor N.A
Explanation of program/service/benefit 
Completion of service in the time promised
Over all performance of the person assisting you

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* 4. Overall, how satisfied or dissatisfied are you with our company?

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* 5. Do you have any other comments, questions, or concerns?

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* 6. Complete this section if you have other comments or questions you would like to discuss. 

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