Customer Satisfaction Survey Form 1.0 (Routine Service Evaluation Form)
In pursuit of service excellence, we are conducting a survey to make our services better by understanding our clients' experience. In line with this, we would like to take a few minutes of your time by answering this survey. There are no right or wrong answers, and all information will be treated with utmost confidentiality.

Team: Health Facilities and Infrastructure Development Team
Bureau/Service/Region: Health Facility Development Bureau
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Name (First Name, Middle Initial, Last Name)
Survey Accomplishment Date *
MM
/
DD
/
YYYY
Sex *
DOH Employee? *
Name of staff who rendered the service? (Write N/A if more than 1 person rendered the service) *
Type of Service Rendered *
If others, please specify type of service rendered.
A. How would you rate your overall expectation of the service provider's service? *
Poor
Excellent
B. Please show the extent to which you think the service provider and their office (if applicable) possess the features described by each statement below:
1. The service provider/s provides its service at the time it promises to do so. *
Strongly Disagree
Strongly Agree
2. You receive prompt service from service providers. *
Strongly Disagree
Strongly Agree
3. The service provider/s is/are polite. *
Strongly Disagree
Strongly Agree
4. The service provider/s is/are sensitive to the client's needs. *
Strongly Disagree
Strongly Agree
5. The service provider/s is/are well dressed and appear neat. (Skip if not applicable or not seen)
Strongly Disagree
Strongly Agree
Clear selection
The appearance of the physical/virtual facility of the service provider is in keeping with the type of service/s provided. (Skip if not applicable or not seen)
Strongly Disagree
Strongly Agree
Clear selection
C. Overall, how would you rate the quality of service provided by the service provider/s? *
For comments, recommendations, concerns, or aspects of our service(s) that needs improvement, please write down below:
Contact details if you wish for us to respond to your feedback:
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