1 How long have you been using the services [ENTER COMPANY/ORG. NAME] provides? Less than one month One to five months Six months eleven months One to three years More than three years Never used before
2 How did you first hear about [COMPANY/ ORG.]? TV Radio Magazine Newspaper Billboard Friend/relative/business associate Never heard about Other, please specify
3 How often do you use/visit [COMPANY/ORG.]? Once a week or more often Between two and three times a month Once a month Less than once a month Never used/visited Other, please specify:
4 Please rate your OVERALL satisfaction with [COMPANY/ORG.]`s service? On a scale from 1 to 6 where 1 is poor and 6 is excellent 1 2 3 4 5 6 N/A 1 2 3 4 5 6 N/A
5 How does the service from [COMPANY/ORG.] compare with service from other organizations?On a scale from 1 to 6 where 1 is poor and 6 is excellent 1 2 3 4 5 6 N/A 1 2 3 4 5 6 N/A
6 As a result of the service you received, will you visit/use [COMPANY/ORG.] again? Definitely Not Probably Not Probably Definitely Not Sure Definitely Not Probably Not Probably Definitely Not Sure
7 Please rate [COMPANY/ORG.] on the following attributes. On a scale from 1 to 6 where 1 is poor and 6 is excellent. 1 2 3 4 5 6 Responsive 1 2 3 4 5 6 Professional 1 2 3 4 5 6 Friendly/courteous 1 2 3 4 5 6 Helpful 1 2 3 4 5 6 Reasonably priced 1 2 3 4 5 6 Honest/Reliable 1 2 3 4 5 6 Fast 1 2 3 4 5 6 High quality 1 2 3 4 5 6 Knowledgeable 1 2 3 4 5 6 Customer service oriented 1 2 3 4 5 6 Well-organized 1 2 3 4 5 6
8 Please rate the IMPORTANCE on these same attributes. On a scale from 1 to 6 where 1 is not important at all and 6 is very important 1 2 3 4 5 6 Responsive 1 2 3 4 5 6 Professional 1 2 3 4 5 6 Friendly/courteous 1 2 3 4 5 6 Helpful 1 2 3 4 5 6 Reasonably priced 1 2 3 4 5 6 Honest/Reliable 1 2 3 4 5 6 Fast 1 2 3 4 5 6 High quality 1 2 3 4 5 6 Knowledgeable 1 2 3 4 5 6 Customer service oriented 1 2 3 4 5 6 Well-organized 1 2 3 4 5 6
11 Based on your experience with [COMPANY/ORG.] will you look for the [COMPANY/ORG.] when seeking similar [GENERIC SERVICE]? On a scale from 1 to 6 where 1 is very unlikely and 6 is very likely 1 2 3 4 5 6 N/A 1 2 3 4 5 6 N/A
12 Is there anything you would like [COMPANY/ORG.] to know about their service that we´ve not already covered?