Form OMBuds Service Eva OMBuds Service Eva OMBuds Service Evaluation Form

OMB Control Number 1225-0088

Expires 10/31/2020

Ombuds Service Evaluation Form

Providing your feedback is of great value to the ombudsman. By receiving and reviewing your evaluation, the Ombuds Service is able to assess and improve the quality of its offerings. Please note that completion of the contact information section below is completely optional. More valuable is your actual feedback. When completed, please click Submit at the bottom of the form.

Name: __________________________________________________ Date: _______________________

Company: __________________________________________ City, State: ________________________

Phone: __________________________________ Email: ______________________________________

Please select the response that most accurately explains your level of agreement with each of the following:

1. I am happy with the outcome of my interaction with the ombudsman.

Strongly Agree Agree Neutral Disagree Strongly Disagree

2. I found it easy to get in touch with and communicate with the Ombuds Service.

Strongly Agree Agree Neutral Disagree Strongly Disagree

3. The ombudsman understood my concern(s) and what I hoped to achieved.

Strongly Agree Agree Neutral Disagree Strongly Disagree

4. Working with the Ombuds Service met my needs and expectations.

Strongly Agree Agree Neutral Disagree Strongly Disagree

5. I would work with the Ombuds Service again should the need and opportunity present themselves.

Strongly Agree Agree Neutral Disagree Strongly Disagree

6. Please feel free to offer any additional comments you might have about working with the Ombuds Service.

The Paperwork Reduction Act of 1995 provides that no person is required to respond to a Federal collection of information unless it displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Responding to this survey is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room N–1301, Washington, DC 20210 or email [email protected] and reference OMB Control Number 1225–0088. Please do not return the completed survey to this address.