Customer Feedback Form

The City of Rock Hill strives to provide you with quality service. Help us to evaluate our service by giving us your opinion of your recent contact with us.

1

Date of Service/Contact

Date of Service/Contact

2

Department/Division that served you:

Department/Division that served you:

3

Name of employee(s) who served you (if known):

Name of employee(s) who served you (if known):

4

Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)

Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)

	1	2	3	4	5
Did we listen attentively to your concern/problem?	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)
How satisfied were you with suggestions offered?	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)
How prompt was our response?	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)
Were you treated courteously?	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)
Did our employee act in a professional and business-like manner?	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)	Please rate the following questions based on a 1 to 5 scale (1 = unsatisfactory and 5 = high satisfaction)

5

Please describe the nature of the service/contact:

Please describe the nature of the service/contact:

6

If you would like a personal follow-up to your concerns, please provide your contact information:

If you would like a personal follow-up to your concerns, please provide your contact information:

First Name:

Last Name:

Email:

Phone Number:

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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