Report prepared by: *

First Name

Last Name

Phone *

(###)

###

####

On what date did you receive your aid shipment? *

MM

DD

YYYY

On a scale from 1-5 (with 5 being the best), how would you rank the quality of the supplies you received? *

1

2

3

4

5

On a scale from 1-5 (with 5 being the best), how well was the shipment organized and easy to unpack? *

1

2

3

4

5

On a scale from 1-5 (with 5 being the best), how would you rank the overall process from request to delivery? *

1

2

3

4

5