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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!
1.Date of Service / Date of Interaction(Required.)
Date (MM/DD/YYYY)
2.I received services from the District Office located in:(Required.)
3.I was assisted with the following services:(Required.)
CalFresh
General Relief
Medi-Cal
CalWORKs
GAIN or Child Care Services
Workforce Connection (WFC)
I'm Applying for:
I'm Receiving:
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