Date of Visit: Time of Day:

1. What was the purpose of your visit?

2. Did you phone before visiting? Yes No

If yes, please answer the following:

a. Was your call answered promptly? Yes No

b. Was the service courteous? Yes No

c. Were you transferred to the correct department for more information? Yes No

3. Were you greeted promptly? Yes No

4. Did office staff give you:

a. Courteous service? Yes No

b. Helpful service? Yes No

c. Accurate information? Yes No

5. How was the service this time compared to your prior visit?

Better Same Worse

When was your last visit?

If you would like a response to your comments, please complete the information below:

Name:

Address:

City, State, Zip:

Daytime Number: