Company Name:		Service Provided:
Date of Event		Contact Person:
# of Participants:

1 = Met needs Exceptionally       3= Needs Met        5= Needs Not Met
	1	2	3	4	5
Service was provided as requested.
Service was delivered in time frame as planned.
Staff performed duties professionally & courteously.
Health screening results were provided in a confidential manner (if applicable).
Staff courtesy
DirectNet case managers
If you ranked any items with a 4 or 5, please provide comments:
Suggestions on how service might be improved in future:
Recommendations for other employee health needs:
Suggestions for community education topics: