ANTI-RED TAPE AUTHORITY
Control No: ___ CLIENT SATISFACTION
(On-Site Version) MEASUREMENT FORM
PSA Approval No.: ARTA-2242-3
Expires on 31 July 2023
Republic of the Philippines
DEPARTMENT OF HEALTH
CENTER FOR HEALTH DEVELOPMENT- NORTHERN MINDANAO
HELP US SERVE YOU BETTER!
This Client Satisfaction Measurement (CSM) tracks the customer experience of government offices. Your feedback on your
recently concluded transaction will help this office provide a better service. Personal information shared will be kept
confidential and you always have the option to not answer this form.
Client type: ☐ Citizen ☐ Business ☐ Government (Employee or another agency)
Date: ___________ Sex: ☐ Male ☐ Female Age: _______
Region of residence: _____________ Service Availed: ________________________________
INSTRUCTIONS: Check mark (✔ ) your answer to the Citizen’s Charter (CC) questions. The Citizen’s Charter is an official
document that reflects the services of a government agency/office including its requirements, fees, and processing times
among others.
CC1 Which of the following best describes your awareness of a CC?
☐ 1. I know what a CC is and I saw this office’s CC.
☐ 2. I know what a CC is but I did NOT see this office’s CC.
☐ 3. I learned of the CC only when I saw this office’s CC.
☐ 4. I do not know what a CC is and I did not see one in this office. (Answer ‘N/A’ on CC2 and CC3)
CC2 If aware of CC (answered 1-3 in CC1), would you say that the CC of this office was …?
☐ 1. Easy to see ☐ 4. Not visible at all
☐ 2. Somewhat easy to see ☐ 5. N/A
☐ 3. Difficult to see
CC3 If aware of CC (answered codes 1-3 in CC1), how much did the CC help you in your transaction?
☐ 1. Helped very much ☐ 3. Did not help
☐ 2. Somewhat helped ☐ 4. N/A
INSTRUCTIONS: For SQD 0-8, please put a check mark (✔ ) on the column that best corresponds to your answer.
N/A
Not
Applicable
Strongly Disagre Neither Agree Strongly
Disagree e Agree nor Agree
Disagree
SQD0. I am satisfied with the service that I availed.
SQD1. I spent a reasonable amount of time for my
transaction.
SQD2. The office followed the transaction’s
requirements and steps based on the information
provided.
SQD3. The steps (including payment) I needed to do
for my transaction were easy and simple.
SQD4. I easily found information about my
transaction from the office or its website.
SQD5. I paid a reasonable amount of fees for my
transaction. (If service was free, mark the ‘N/A’
column)
SQD6. I feel the office was fair to everyone, or
“walang palakasan”, during my transaction.I am
confident my online transaction was secure.
SQD7. I was treated courteously by the staff, and (if
asked for help) the staff was helpful.
SQD8. I got what I needed from the government
office, or (if denied) denial of request was sufficiently
explained to me.
Suggestions on how we can further improve our services (optional):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________
Email address (optional): __________________________________
THANK YOU!
