For the best response to YOUR feedback and comments, please complete all requested

fields.
On a scale of 1 to 5, please RATE our service.

Grade (5) is for Excellent evaluation (85% to 100%)

Grade (4) is for Good evaluation (75% to 85%)

Grade (3) is for Average evaluation (60% to 75%) Acceptance Limit

Grade (2) is for Poor evaluation (30% to 60%)

Grade (1) is for Terrible evaluation (0% to 30%)

1. How would you Overall rates ------? 6. How satisfied are you with ----- Response to on-
call troubleshooting, emergency cases or
unplanned work?

1 2 3 4 5 1 2 3 4 5
Terrible Excellent Terrible Excellent

2. How satisfied are you with ------ Quality of 7. How satisfied are you with ------ Delivery Time
Service/Products /Technical support? of service & consistency with schedules?

1 2 3 4 5 1 2 3 4 5
Terrible Excellent Terrible Excellent

3. How satisfied are you with ------ Personnel 8. How satisfied are you with ----- Logistics
Performance? Support?

1 2 3 4 5 1 2 3 4 5
Terrible Excellent Terrible Excellent

4. How satisfied are you with ----- HSE 9. If you could change something about ------
Performance? Performance what would it be?
--------------------------------------------------------------------------------
1 2 3 4 5 --------------------------------------------------------------------------------
Terrible Excellent
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------

5. How satisfied are you with ----- in Supplying 10. Other Comments?
Information and data or technical advises?
---------------------------------------------------------------------------
------------------------------------------------------------------------------------
1 2 3 4 5
Terrible Excellent ------------------------------------------------------------------------------------
------------------------------------------------------------------------------------

(CSP/812/02/00/02)
 Customer Satisfaction Questionnaire
This form is for continues improvement only
And will not be used in any marketing or
Commercial purposes
On behalf of everyone at our company thank you for your feedback. We value you as a customer and will
take your input into consideration while providing our products and/or services in the future. We are
delighted to hear from you. You can expect us to respond to your patronage as soon as possible.

Again, thank you for your patronage. We look forward to serving you.

Company / Organization :
Project :
Activity Description :
Discipline :

Customer Personal contact/information:

Name : Signature :
Title :
Phone :

Fax :

E-mail :

------------ Company
------- representative name ………………………..

Signature ……………………….

Date / /

If for any reason you have questions or comments please Contact:

QHSE Department.
---------- Co.
Address
Tel.:
Fax:
E-mail:
Web site:

(CSP/812/02/00/02)