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2. Thank you for giving Cochise Health and Social Services/Vital Records (CHSS) the opportunity to serve you better. Please help us by taking a moment to tell us about the service you have received so far. We appreciate our relationship and want to make sure we fully meet your expectations. Simply indicate your degree of agreement with each of the statements that follow.
4. Where did you receive services?

   1. Bisbee
   2. Benson
   3. Sierra Vista

   1. Willcox
   2. Douglas
   3. Client's Home or Business
6. CHSS Staff Are Knowledgeable

   1. Strongly Disagree
   2. Somewhat Disagree
   3. Neither Agree nor Disagree
   4. Somewhat Agree
   5. Strongly Agree
   6. N/A
8. CHSS Staff Answer All of My Questions/Concerns

   1. Strongly Disagree
   2. Somewhat Disagree
   3. Neither Agree nor Disagree
   4. Somewhat Agree
   5. Strongly Agree
   6. N/A
10. CHSS Staff Adhered to Professional Standards of Conduct

    1. Strongly Disagree
    2. Somewhat Disagree
    3. Neither Agree nor Disagree
    4. Somewhat Agree
    5. Strongly Agree
    6. N/A
12. CHSS Staff Respond to My Inquiries in a Timely Manner

    1. Strongly Disagree
    2. Somewhat Disagree
    3. Neither Agree nor Disagree
    4. Somewhat Agree
    5. Strongly Agree
    6. N/A
14. Overall, I Am Very Satisfied with CHSS Staff

    1. Strongly Disagree
    2. Somewhat Disagree
    3. Neither Agree nor Disagree
    4. Somewhat Agree
    5. Strongly Agree
    6. N/A
16. Please Indicate the Date of Your Last Interaction with CHSS Staff
    Please Indicate the Date of Your Last Interaction with CHSS Staff
18. Please Add Any Other Comments or Suggestions You Wish to Share with Us
20. If You Wish to Be Contacted by a Member of CHSS Management, Please Provide Us with Your Name and Phone Number or Email Address
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22. 1. Receive an email copy of this form.
23. Email address

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24. Submit

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