NYC Feedback: Customer Survey

1. Please provide your contact information (Optional):

First Name

Last Name

Email Address

Phone Number

2. Agency Name: Required Question

3. What is your primary language? Required Question

4. Where did you interact with our agency staff? Required Question

5. Please list the address:

6. Please list the phone number:

7. Please list the address or email address:

8. Please rate the professionalism and courtesy of the agent who served you: Required Question

9. Please evaluate how clearly the rules and important information were communicated. Required Question

10. How would you rate the overall customer service provided? Required Question

11. What was the date/time you interacted with this staff person (please respond to the best of your abilities):

12. Additional Comments

	English
	Spanish
	Chinese - Cantonese
	Chinese- Mandarin
	Russian
	Korean
	Italian
	Haitian Creole
	Other (please name your primary language)

Poor	Fair	Average	Good	Excellent

Poor	Fair	Average	Good	Excellent

Poor	Fair	Average	Good	Excellent