Health System Services is committed to offering the best customer service in the industry. In that effort, we ask for your input on how we are doing, and how we can improve. Please take a few minutes to complete the following brief questionaire.

Please enter survey code:

Name
Address
City/St/Zip
Email
Position		Not applicable for homecare patients

Please rate HSS on the following scale:

Telephone Support:	Poor	Fair	Good	Very Good	Excel- lent
Friendliness
Ability to answer questions
Overall telephone support
Personal Visits by Customer Service Rep:
Friendliness
Ability to answer questions
Overall telephone support
Delivery Personnel:
Friendliness
Appearance
Willingness to go the extra mile
Overall delivery personnel
Miscellaneous:
Accuracy of deliveries
Timeliness of emergency deliveries
Product availability
After hours Answering Service
Overall:
Please rate our service overall
Overall are you satisfied with our service?	Yes / No

Please name any HSS employee
you feel does an exceptional job:

Suggestions on how we can improve:

May we use you as a reference?  Yes / No
Is there anyone you feel we should contact about our service? Yes / No

If yes, Name(s)	Facility(if applicable)

Comments:

= Mandatory Field