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BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov Louise R. Bailey, MEd, RN, Executive Officer

Customer Service Evaluation Form

Name: Address: City: Telephone Number: Work: State: Home: Zip: Date:

What was the nature of your contact with the board?

Date of Contact/Service: How was this contact made? This is a (please check appropriate box):

Employee(s) contacted (if known):

by phone

by mail Complaint or

in person Comment

Description of situation (please use additional pages if needed):

Has the problem been resolved? If not, what resolution are you requesting?

Yes

No

What suggestions would you provide to the board to avoid such a problem in the future?

Thank you!

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