Customer/companion Feedback Form
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3Department of Children and Families
Customer/Companion Feedback Form
(To be completed by clients/customers who are Deaf or Hard‐of‐Hearing Only)
The Department of Children and Families is committed to providing excellent customer service. We value your opinion and
request that you complete this short survey to assist us in evaluating and improving our services. While you are not
required to respond, we thank you in advance for completing this survey. The survey is ANONYMOUS; therefore, please do
not provide your name or any other personal information UNLESS YOU WOULD LIKE TO BE CONTACTED. Please complete
the form and submit it to the local office or mail to: Department of Children and Families, Office of Civil Rights, 1317
Winewood Boulevard, Building 1, Room 110, Tallahassee, Florida 32399‐0700.
IF YOU NEED ASSISTANCE IN COMPLETING THIS FORM PLEASE NOTIFY STAFF OR CONTACT THE OFFICE
OF CIVIL RIGHTS AT (850) 487‐1901 OR TDD (850) 922‐9220
Please provide a response to the following:
1
Are you a:
Client/Customer
Companion
who is deaf or hard‐of‐hearing?
2
Were you provided any assistive services and technologies? (Please check all that were provided.)
Certified Interpreter
Qualified Staff
VRS
Pocket Talker
Motiva
CART
Other: _____________
3
Were the assistive services and technologies effective?
Yes
No (If no, please explain.)
4
Were you denied assistive services and technologies?
Yes (If yes, please complete #5)
No
a. What was requested? _____________________________
b. What was provided? ______________________________
5
If you answered yes to #4, please provide the reason you were given for denial of the requested assistive
services and technologies?
6
Did you agree with the agency’s decision given for the denial of the requested assistive services and
technologies? If no, why?
7
The request for assistive services and technologies was made:
Before the Appointment
Onsite
8
Provide date(s) assistive services and technologies were requested and provided.
My request for assistive services and technologies was made to the agency on:
a.
(MM/DD/YYYY)
b. Date assistive services and technologies were provided by the agency:
(MM/DD/YYYY)
9
Were the assistive services and technologies provided within two hours of your request?
Yes
No
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(U:HHS Forms/Customer Feedback Form) 5/17/2011
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