CLIENT FEEDBACK FORM Control No.

: 0080

Your experience matters to us!

I. Client Information

Name (Optional): ________________________________________Date Visited: 01/11/2021_

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.
CLIENT FEEDBACK FORM Control No.: 0080

Your experience matters to us!

I. Client Information

Name (Optional): ________________________________________Date Visited: 01/18/2021_

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.
CLIENT FEEDBACK FORM Control No.: 0080

Your experience matters to us!

I. Client Information

Name (Optional): ________________________________________Date Visited: 01/25/2021_

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.
CLIENT FEEDBACK FORM Control No.: 0080

Your experience matters to us!

I. Client Information

Name (Optional): ________________________________________Date Visited: 06/07/2021_

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.
CLIENT FEEDBACK FORM Control No.: 0080

Your experience matters to us!

I. Client Information

Name (Optional): ________________________________________Date Visited: 06/14/2021_

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.
CLIENT FEEDBACK FORM Control No.: 0080

Your experience matters to us!

I. Client Information

Name (Optional): ________________________________________Date Visited: 04/05/2021_

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.

CLIENT FEEDBACK FORM Control No.: 0080

 Your experience matters to us!

I. Client Information

Name (Optional): ________________________________________Date Visited: 04/12/2021

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.

CLIENT FEEDBACK FORM Control No.: 0080

Your experience matters to us!

I. Client Information

Name (Optional): ________________________________________Date Visited: 04/19/2021_

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.

CLIENT FEEDBACK FORM Control No.: 0080

Your experience matters to us!

I. Client Information
Name (Optional): ________________________________________Date Visited: 01/21/2021_

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.
Name (Optional): ________________________________________Date Visited: 05/17/2021_

Office Visited: san Agustin Elementary School Phone No. (Optional) ___________

Purpose of Visit (Please specify): To get Modules for my children

Time Started: 8:30 am Time Finished: 11:30 am

II. Client Satisfaction Rating

Kindly rate the quality of service provided by checking () the appropriate box.

Very Dissatisfied Neutral Satisfied Very

Dissatisfied Satisfied
1. PHYSICAL
The environment is clean and /
orderly.
2. SERVICES
Your concern was addressed /
promptly and appropriately.
3. PERSONNEL
The employee was courteous /
and accommodating
*OVERALL RATING FOR THE
SERVICE PROVIDED? /

III. Suggestions/Compliments/Comments

Please keep up the good work.. Thank you!

______________________________________________________________________________

Thank you for your valuable input to help us continuously improve our services!

Privacy Notice:
The personal information included in this document should only be used for the purposes of administering the survey.
Any personal information included herein may not be used for other purposes aside from those stated above.