Satisfaction Survey:
?  Frequently Asked Questions  ?

SECTION I (to be completed by the provider)
Enter either the Clinic Number OR the Facility Name and the other will automatically be entered for you.
Clinic Number (facility code):
 		Facility Name:
Date Survey Taken:
 		Today's Date:
Is this client a prevention participant?
 Choose Yes or No below.  Based on your choice, you will be taken to a new page with the information required for the client
.

If Yes, Click Here

   If No, Click Here

Client Identifier (SSN#)