Appendix D
Sample Client Satisfaction Survey
14
Thank you for your participation in the (PROGRAM NAME) at (RESTAURANT)! The
(AGENCY NAME) would like to know about your experience as a client of the program.
Please complete the survey below and return by mail to:
(AGENCY NAME)
(ADDRESS)
(ADDRESS)
1. At what mealtime do you dine at the restaurant? Select all that apply.
☐ Breakfast ☐ Lunch ☐ Dinner
2. What type of meal(s) did you receive? Select all that apply.
☐ Dine In ☐ To-Go
3. How many days per week do you dine with (PROGRAM NAME) at (RESTAURANT)?
☐ 1 – 3 ☐ 3 – 5 ☐ 5 – 7
Please rate your level of satisfaction for the following:
Very
Satisfied
Somewhat
Satisfied
Neutral
Somewhat
Satisfied
Very
Dissatisfied
Quality of the meals received
☐
☐
☐
☐
☐
Taste of the meals received
☐
☐
☐
☐
☐
Menu options for meals
☐
☐
☐
☐
☐
Customer service at restaurant
☐
☐
☐
☐
☐
Process to redeem meal vouchers
☐
☐
☐
☐
☐
Cleanliness of dining area
☐
☐
☐
☐
☐
Use the space below to share any additional feedback. Please provide comments to any
statements you noted as “dissatisfied” or “very dissatisfied.”
We appreciate your feedback!
