Consumer Satisfaction Survey Form

INTRA-NATIONAL HOME CARE, LLC

CONSUMER SATISFACTION SURVEY

Name of Consumer *

FOLLOWING QUESTIONAIRE SURVEY MEASURE THE SATISFACTION OF SERVICES PROVIDED BY INTRA-NATIONAL HOME CARE TO CONSUMER. SO PLEASE HELP US TO COMPLETE THIS SURVEY WITH YOUR LEVEL OF SATISFACTION WITH OUR AGENCY.

1. How would you rate the service you received from the staff of Intra-National Home Care, LLC?

Excellent

Good

Fair

Poor

2. How would you rate Intra-National Home Care, LLC staff based on their job knowledge and skills?

Excellent

Good

Fair

Poor

3. How you rate the Intra-National staff’s attitude and honesty?

Excellent

Good

Fair

Poor

4. What is your satisfaction level with DCW services?

Excellent

Good

Fair

Poor

5. How polite and honest is DCW with you?

Excellent

Good

Fair

Poor

6. How is the companionship of DCW on you?

Excellent

Good

Fair

Poor

7. Please rate the quality of the services you received from us:

Excellent

Good

Fair

Poor

8. Please rate the information we provided on our website:

Excellent

Good

Fair

Poor

9. Please rate our staff in terms of efficiency:

Excellent

Good

Fair

Poor

10. Please rate our responsiveness to feedback:

Excellent

Good

Fair

Poor

11. Please rate your overall experience with our services:

Excellent

Good

Fair

Poor

12. Would you recommend us to friends and family?

Yes

No

Reason:

Name of Consumer *

Date