First Name:

Last Name:

Email:
Login ID:

Work Order/Tract Order #:

Date of Services: (yyyy-mm-dd)

Location(s):


Name of officer(s)/staff(s)/coordinator(s) at the service site(s):
  1. Name:
    Job Title (optional):
    Email:
  2. Name:
    Job Title (optional):
    Email:
  3. Name:
    Job Title (optional):
    Email:

Subject matter:

Service ended and adjourned by (name of staff):


Any prior preparation before the site service:
Yes       No
Hour(s) spent on preparation:

Total hour(s) billed (site services + preparation)
    Hour: Minute:
FeedBack:
  1. Do you think the information provided to you prior to the service is adequate for you to accomplish your goal?
    10 
  2. Do you think the outcome was satisfying?
    10 
  3. Do you think officer(s)/staff(s)/coordinator(s) was clear about his/her objectives?
    10 
  4. Do you think the community you served on the site beneficial from this service?
    10 
  5. Were there any issue(s) that needed improvements?
    No  Yes 
    Please explain:


Yes, I have provided all the info to the best of my knowledge and I understand this copy report will be sent to service requester and CELS agency.



To ensure best services, please take a few minutes to give us your response. Thank you.
  1. Do you think the outcome was satisfying?
    10 
  2. Do you think the CELS liaison was clear about his/her objectives?
    10 
  3. Do you think the community you served on the site benefit from this service?
    10 
  4. Were there any issues that needed improvements?
    No  Yes 
    Please explain:
  5. From scale 1 to 10, what will you rank this?
    10 

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