2016 Provider Satisfaction with CFST Survey

North Central

Date (mm/dd/yy):

1).	Name of CFST surveying agency who visited your facility location to complete consumer satisfaction surveys (choose one):

2).	Were the surveyors respectful?

	If you answered "Not respectful", please explain:

3).	Did the surveyors do a good job?

	If you answered "Not good", please explain:

4).	Were the surveyors professional?

	If you answered "Not professional", please explain:

5)	Please add any additional comments you have regarding the surveyors or the survey:

6).	In which county is your facility located that was visited by the CFST:

7).	What level of care did the CFST survey? (Choose all that apply. To choose multiple levels of care, please hold down the Ctrl Key and click on each answer choice.)

	If Other, please list level of care below:

Please hit the SUBMIT button when you have completed the survey.

Thank you for taking the time to complete the survey.

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