Free Customer Feedback, HCF 16104 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 16104 (08/07)

STATE OF WISCONSIN

LOCAL AGENCY CUSTOMER FEEDBACK
In order to better serve you, we ask that you fill out this form about your visit to our office today. You do not need to put your name, address or telephone number on this form. All answers will be kept private. Please read each statement below and check the box that best describes how you feel. If the statement does not apply to you, check the "N/A" box. When you are done, please put both copies in the box provided. Thank you for your help.

Today's Date

What County or Tribal agency are you visiting today?

1.

Overall, I am satisfied with the services I have received in the office today. Strongly Agree Agree Disagree Strongly Disagree N/A

2.

I understood when the staff told me about programs and services I could get. Strongly Agree Agree Disagree Strongly Disagree N/A

3.

The staff told me about FoodShare Medicaid/BadgerCare Other

4.

The staff treated me fairly and with respect. Strongly Agree Agree Disagree Strongly Disagree N/A

5.

The staff was helpful. Strongly Agree Agree Disagree Strongly Disagree N/A

6.

I understood when the staff told me what I needed to do to get and keep benefits. Strongly Agree Agree Disagree Strongly Disagree N/A

7.

The staff returns my telephone calls within.... 1 Day 2 Days 3 Days Has not returned my calls

8.

I am able to get to the office during the hours it is open. Strongly Agree Agree Disagree Strongly Disagree N/A

9.

How do you most like to contact the office when you need help or have a question? In person By phone By mail By email

Use this space, to write down anything else you would like to tell us.

Agency Use Only -- Send completed forms quarterly to: DHFS/DHCF/BEM/Program Management Section, 1 West Wilson, Room 1050, Madison, WI. 53703