EnVision Center Survey

2528-XXXX

Expiration Date: XX-XX-XXXX

EnVision Center Customer Satisfaction (Services Sought) Survey

1. What was the purpose of your visit today? Mark all that apply.

Employment opportunities Job training Financial literacy Tax assistance Benefits counseling

VA benefits counseling Education resources Healthcare services Health information Family/dependent care services

Civic engagement Volunteerism Mentorship Youth programs Other

2. How did you learn about the EnVision Center?

• Friend/family

• Landlord/housing provider

• Social services program/Health and Human Services program

• Website/social media

• Other

3. Are you clear about the types of services and supports you can receive from the EnVision Center?

• Very clear

• Somewhat clear

• Not clear

4. How satisfied are you with the assistance you received from EnVision Center?

• Very satisfied

• Somewhat satisfied

• Somewhat dissatisfied

• Very dissatisfied

5. What is the zip code in which you reside? ___________________

6. What is your gender?

• Male

• Female

7. What is your age? ___________________

8. Are you of Hispanic, Latino, or Spanish origin?

• No, not of Hispanic, Latino, or Spanish origin

• Yes, of Hispanic, Latino, or Spanish origin

9. What is your race? Mark all that apply.

• American Indian/Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

Public reporting burden for this collection of information is estimated to average 0.05 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection information unless that collection displays a valid OMB control number 2528-XXXX, expiring xx-xx-xxxx.The information requested under this collection is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C.552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130. As required by 5 U.S.C. 552a (Privacy Act of 1974).