Customer Survey

Office:

Select Service Provider
Who Provided Service

Select The Date of Your Contact
Select Date

Type Of Visit?

Please Check One Response in Each Category

Category	Excellent	Good	Fair	Poor	Not Applicable
Did You Receive Timely Service
Were The Facilities Clean
Were The Facilities Comfortable
Were Employees Knowledgeable
Were Employees Friendly & Courteous
How was Your Overall Experience
Were Your Needs Fulfilled
Was Your WEB Contact Completed Satisfactorily

If You Would Like to Be Contacted Please Provide the Information Below
First Name	Last Name

Address

City

State

Zip

E-Mail

Phone Number

All Information Will Be Maintained by the Broward County Health Department

No Information will be sold or disseminated to third parties