 
Sample Customer Satisfaction Survey/ Sample Questions for Customer Satisfaction Survey
Understanding why recent customers do not plan to return to a particular store, this survey addresses reasons for dissatisfaction and requests suggestions on how the store can improve.
Do you ever plan to return to this store?
	| Yes | 
| No | 
Overall, please rate the quality of customer service that you received during this visit.
	What were the main reasons for the poor quality of customer service? Please select all that apply.
	| Not attentive enough | 
| Too pushy | 
| Not knowledgeable enough | 
| Rude | 
| Disrespectful | 
| Did not listen to my needs | 
| Too slow | 
| Other (please specify)	 | 
Did you file a formal complaint regarding the customer service?
	| Yes | 
| No | 
When was this complaint filed?
	| During the visit to the store | 
| After the visit to the store | 
Did anyone from the store follow-up with you about the complaint?
	| Yes | 
| No | 
Would you like a store representative to contact you?
	| Yes | 
| No | 
If you answered "yes" to the previous question and would like a store representative to contact you, please indicate your preferred telephone number here.
	Were you satisfied with the follow-up to your complaint?
	| Yes | 
| No | 
Why weren't you satisfied with the follow-up to your complaint?
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	Overall, please rate the quality of the appearance of the store during this visit.
	What were the main reasons for the poor appearance of the store? Please select all that apply.
	| Messy/Too much clutter | 
| Dirty | 
| Too crowded (e.g. aisles weren't big enough) | 
| Interior decoration was unappealing | 
| Exterior space was unappealing | 
| Other (please specify) | 
Overall, please rate the quality of the product(s)/service(s) provided by this store.
	What were the main reasons for the poor product(s)/service(s)?
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	How likely is it that you will go to another store to obtain the product(s)/service(s)?
	Please provide any suggestions for improving the quality of the store with respect to customer service, appearance, product/service, etc.
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	How many times have you visited this store location in the past?
	| None | 
| 1 to 2 times | 
| 3 to 5 times | 
| 6 to 10 times | 
| 11 or more times | 
What was the product(s)/service(s) you were shopping for when you visited this store? Please select all that apply.
	| Product/Service 1 | 
| Product/Service 2 | 
| Product/Service 3 | 
| Product/Service 4 | 
| Product/Service 5 | 
Was this the first time you purchased the product(s)/service(s) from any store?
	| Yes | 
| No | 
What is your gender?
	| Female | 
| Male | 
What is your age?
	| 18 to 25 | 
| 26 to 34 | 
| 35 to 49 | 
| 50 to 64 | 
| 65 and over | 
What is the highest level of education that you have achieved?
	| Less than high school degree | 
| High school degree or GED | 
| Associates degree or trade school | 
| College degree | 
| Graduate school degree | 
What was your household income last year?
	| $0 to $24,999 | 
| $25,000 to $49,999 | 
| $50,000 to $74,999 | 
| $75,000 to $99,999 | 
| $100,000 to $124,999 | 
| $125,000 to $149,999 | 
| $150,000 or more | 



