* 1. Briefly describe your request:

* 2. Did you receive a timely response to your request?

* 3. Was staff courteous?

* 4. Were you satisfied with the explanation or results?

* 5. How would you rate your overall experience?

6. Comments (Areas of praise or improvement):

Please provide the following information (optional):

7. Name (Last, First):

8. Street Address

9. Home Phone

10. E-Mail:

11. Would you like to be contacted regarding this issue?