Customer Satisfaction Survey Form

To help us improve our services to you, please take a minute to respond to the following statements. Check the response that best describes your opinion. Please begin by supplying us Program information.

Please enter the service with which you had contact.

If Other, please specify:

Please enter the nature of the contact.

If Other, please specify:

Please enter the approximate date of the contact.

(MM/DD/YYYY)

Are you a ...

If Other, please specify:

In the course of the contact I made for services I was treated:

Very Well Adequately Not Well

The services were provided to me when I wanted them.

Strongly Agree Agree Strongly Disagree Not Applicable

My overall satisfaction with the services provided to me may be described as:

Completely Satisfied Satisfied Not Satisfied

Would you recommend the services of the Iowa Civil Rights Commission to a friend or member of your family?

Yes No Unsure

Please explain any issues or concerns you had with the Commission's service, or provide any additional comments, in the text box below.

The Iowa Civil Rights Commission appreciates your input.