SERVICE USER FEEDBACK FORM Service User Feedback Form 1. Which service have you accessed? 2.What is your gender? Male Female Rather not say 3.What age are you? 0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 4.What is your ethnic group? White Mixed/Multiple Ethnic groups Asian/Asian Black Black/African/Caribbean/Black British Other ethnic group 5.Which part of the county do you live in? Worcester Dudley Birmingham Romsley Stourbridge 6.We would like you to think about your most recent experience of the service you have accessed. What was good about your visit? 7.What would have made it better? 8. Overall, how was your experience of our service? Very Good Good Neither good nor poor Poor Very Poor Don't know 9. Please tell us why you have given that answer. 10. Please tick this box if you do not wish your comments to be made public. SUBMIT