Agency Survey

Date Survey Completed *

What could we have done to increase your satisfaction? *

OUR PERFORMANCE - How did we do in the following areas?

What could we have done to improve our performance?

Comment *

Were you told about other programs or services that would meet your's or your family's additional needs? *

Yes No, had no other need No, but had other needs

Please list the services you were told about. *

Did you experience any problems with the service(s) you received? *

Yes No

If you did experience any problems, please explain the problem. *

Is this the first time you have received this service through our agency? *

Yes No I have received other services, just not this one

What other services would you like JVCAI provide? Please be specific. *

Please include any other comments you would like us to know. *

THANK YOU FOR COMPLETING THE SURVEY!

Completing this portion is optional. However, if you would like us to contact you in regards to the survey you have listed you must provide your contact information.

Address *

Line 1

Line 2

City

State

Zip Code

Country

Can We Contact You Via Texting? *

Yes No

Please List the Best Way to Reach You. *

Best Time to Reach You (please check all that apply). *

Morning Afternoon Any

Primary Phone Number *

Cell Phone Number *

JVCAI Agency Survey

We would like to know what you think about our programs and services. Your feedback is very important to us and will be used to improve and/or expand our services. Thank you for your help!

Completing this portion is optional. However, if you would like us to contact you in regards to the survey you have listed you must provide your contact information.

Jackson-Vinton Community Action, Inc.
118 S. New York Avenue
Wellston, Ohio 45692

PROVIDING SERVICES TO jACKSON AND Vinton cOUNTIES

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Hours

Telephone

Email Executive Director