Self Sufficiency Customer Satisfaction Survey

Location and Service(s)

Please take a few moments to provide us with your feedback, comments and/or concerns by filling out the following survey. Thank you for taking the time to help improve our customer service!

Question Title

* 1. Date of Service / Date of Interaction

Date (MM/DD/YYYY)

Date

Question Title

* 2. I received services from the District Office located in:

Question Title

* 3. I was assisted with the following services:

	CalFresh	General Relief	Medi-Cal	CalWORKs	GAIN or Child Care Services	Workforce Connection (WFC)
I'm Applying for:	I'm Applying for: CalFresh	I'm Applying for: General Relief	I'm Applying for: Medi-Cal	I'm Applying for: CalWORKs	I'm Applying for: GAIN or Child Care Services	I'm Applying for: Workforce Connection (WFC)
I'm Receiving:	I'm Receiving: CalFresh	I'm Receiving: General Relief	I'm Receiving: Medi-Cal	I'm Receiving: CalWORKs	I'm Receiving: GAIN or Child Care Services	I'm Receiving: Workforce Connection (WFC)