Customer/companion Feedback Form Page 2

Department of Children and Families

Customer/Companion Feedback Form

(To be completed by clients/customers who are Deaf or Hard‐of‐Hearing Only)

If no, what was the timeframe after the request was made? ______________

10 Were you aware or informed that all assistive services and technologies were at no cost to you?

Yes

11 At what DCF location or Contract Agency did you receive services?

12 Were services provided to you in a fair manner?

Yes

a)If no, please explain.

b)Do you feel you were discriminated against?

If so, please provide your contact information. (This is optional)

13 Did staff treat you with respect?

Yes

If no, please explain.

14 What assistance did you receive in completing this form, if any?

15 Additional Comments:

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(U:HHS Forms/Customer Feedback Form) 5/17/2011

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Parent category: Business