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Example A-11 Form Template from Touchpoints Wiki

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page 1 of 2
I am satisfied with the service I received from [Program/Service name].) *
This interaction increased my confidence in [Program/Service name]. OR I trust [Agency/Program/Service name] to fulfill our country's commitment to [relevant population]. *
Would you like to take two more minutes to answer more questions to help us improve our services?
Yes, keep going →
page 2 of 2
My need was addressed.
It was easy to complete what I needed to do.
It took a reasonable amount of time to do what I needed to do.
I was treated fairly.
Employees I interacted with were helpful.

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