Form 0917-0036-21 OMB No 0917-0036-21, Portland Area Division of Environme

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PORTLAND AREA DIVISION OF ENVIRONMENTAL HEALTH SERVICES: CUSTOMER SERVICE
ASSESSMENT
The Environmental Health Services (EHS) program wants to provide the best services possible.
Please take a few minutes to respond to the questions below. Your input helps us set priorities for improvement.

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Q1

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*1. Tribe or community where you live or where you received services.

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Q2

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2. Program you work for (if services received through work):

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Q3

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3. EHS Staff who provided services:
CDR Karin Knopp
LCDR Stephanie Coffey
LCDR Shawn Blackshear
Ms. Lorna Morgan
Ms. Alyssa Bernido
Ms. Holly Thompson
CDR Nancy Collins
LT Matthew Ellis
CDR Celeste Davis
Other (please specify)

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Q4

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4. When did you receive services?
MM
Date

DD
/

YYYY
/

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Quality of Service

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*5. Service or technical assistance met the needs or resolved the issue.
Yes
No
Don't Know

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Other (please specify)

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*6. Assessment, findings, and corrective actions clearly explained.
Yes

No

N/A

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Comments

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*7. Quality of information, outcome or survey report.
Excellent

Good

Average

Fair

Poor

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Quality of Staff

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Q8

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*8. Professionalism and courtesy of the EHS representative.

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Excellent

Good

Average

Fair

Poor

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*9. Level of understanding and concern shown by EHS staff about the program or issue.
Excellent

Good

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Fair

Poor

Fair

Poor

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*10. Knowledge and information provided by EHS staff.
Excellent

Good

Average

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Process

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Q11

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*11. Response time to answer your question(s), return your phone call or email, or provide you with a result or
written report.
Prompt, timely

Took too long

Please indicate your
response by checking the

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Prompt, timely

Took too long

box that represents your
view.
Other (please specify)

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Overall

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*12. How would you rate the staff, services, and products provided by EHS?
Excellent

Good

Average

Fair

Poor

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view.

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13. What do you like best about the services provided by the Environmental Health Services program?

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14. What can EHS do better?

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15. If you would like us to contact you, please leave your information. Thanks!
Name:
Company:
Address:
Address 2:
City/Town:
-- select state --

State:
ZIP:
Email Address:
Phone Number:

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0036. The time
required to complete this information collection is estimated to average 15 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S.
Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201,
Attention: PRA Reports Clearance Officer.

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