NICC Survey Form

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Survey Form

Enter the Visited Office/Department/Room #:

Employee or Staff who provided service

Purpose or Intention in coming here:

Received the appropriate services needed:

Timely response was given:

The staff was well informed:

The staff was courteous and approachable:

The services rendered were just, honest and fair:

The health facility was clean and organized:

Duration of waiting before needs are addressed:

Hour: Minute:

Overall, are you satisfied with the service/information you have received?

Yes No

Comments / Suggestion (if any)

Contact Information (Optional)

Fullname

Contact Number

Please fill out all fields marked with an asterisk (*).

Data Privacy Notice

The personal information and data collected in this form is used for NICC's service improvement and to communicate with patients/companions, as needed. All information collected through this form are stored in a secure location in NICC, accessed by authorized staff. No data is shared with any external group. Data collected will be deleted one year from date of accomplishment.