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    OMB Form 11 - Feedback Form

    Uploaded by

    Noreen Aquino
    This is a feedback form from the Office of the Ombudsman in the Philippines that collects client information and satisfaction ratings for 9 service categories on a scale from poor to excellent. It asks for the client's name, contact details, and the service requested. The form also has space for recommendations or reasons for

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    OMB Form 11 - Feedback Form

    Uploaded by

    Noreen Aquino
    29 views1 page
    This is a feedback form from the Office of the Ombudsman in the Philippines that collects client information and satisfaction ratings for 9 service categories on a scale from poor to excellent. It asks for the client's name, contact details, and the service requested. The form also has space for recommendations or reasons for

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    This is a feedback form from the Office of the Ombudsman in the Philippines that collects client information and satisfaction ratings for 9 service categories on a scale from poor to excellent. It asks for the client's name, contact details, and the service requested. The form also has space for recommendations or reasons for

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    29 views1 page

    OMB Form 11 - Feedback Form

    Uploaded by

    Noreen Aquino
    This is a feedback form from the Office of the Ombudsman in the Philippines that collects client information and satisfaction ratings for 9 service categories on a scale from poor to excellent. It asks for the client's name, contact details, and the service requested. The form also has space for recommendations or reasons for

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    OMB Form 11 - Revised 2021

    Republic of the Philippines


    Office of the Ombudsman
    Agham Road, Diliman, Quezon City

    FEEDBACK FORM (OMB FORM 11)


    We value your feedback.
    Please let us know how well we have served you by completing this form.
    SERVICE REQUESTED
    1 Application for Ombudsman Clearance 7 Transmittal of SALNs
    Request for Assistance (RAS) /
    2 8 Request for Copy of SALN/s
    Other Forms of Assistance (OFA)
    Request for Copy of SALN/s of OMB Officials and
    3 Filing of Complaint 9
    Employees
    4 Submission of Pleadings and Other Documents 10 Redress of Client Complaint or Grievance

    5 Request for Copy of Complaint and Case Documents 11 Others, please specify

    6 Request for Complaint / Case Information

    Area/Sector:

    Name of Office/Bureau:
    Name of OMB Personnel
    who attended the client:
    Time of
    Date of Visit: AM PM
    Visit

    Name of Client (Optional):

    Contact Number:

    Sex: Male Female Age:

    How would you rate our service? Please put a check (/) mark.
    (Paano po ninyo bibigyan ng marka/grado ang aming ibinigay na serbisyo?
    Poor Unsatis- Satisfac-tory Excellent
    Very Satisfac-
    (Lubhang factory (Kasiya-siya) (Napaka-
    tory
    Di -kasiya- (Hindi kasiya- husay)
    Category (Kategorya) (Lubos na
    siya) siya)
    kasiya-siya)
    (4)
    (1) 2) (3) (5)

    1. Responsiveness (Willingness to help, assist, and


    provide prompt service to citizens/clients)
    2. Reliability (Quality) (Provision of what is needed
    and what was promised,
    following the policy and standards, with zero to a
    minimal error rate)
    3. Access and Facilities (Convenience of office
    arrangements and location of transaction areas,
    ample amenities for comfortable transactions, use
    of clear signages and modes of technology)

    4. Communication (Keeping the citizens and clients


    informed in a language they can easily understand,
    as well as listening to their feedback)

    5. Costs (Reasonableness of the required fees and


    information on the amount to be paid, if any, and
    availability of other payment methods, e.g., postal
    money order or Landbank LinkBiz.)
    6. Integrity (There is honesty, justice, fairness, and
    trust in each service while dealing with the
    citizens/clients)
    7. Assurance (Capability of frontline staff to
    perform their duties, product and
    service knowledge, understanding citizen/ client
    needs, helpfulness, and good work
    relationships)
    8. Outcome (Extent of achieving outcomes or
    realizing the intended benefits of
    government services)
    9. Overall Satisfaction Rating (I am fully satisfied
    with the overall service of the action officer)

    Recommendation(s)/Suggestion(s)/Desired Action from our Office


    or What are your reason(s) why you did not answer the feedback form?
    (Rekomendasyon/Mungkahi/Nais na aksiyon mula sa aming tanggapan o Ano po ang inyong dahilan
    kung bakit hindi po kayo sumagot sa aming feedback form?)

    Maraming salamat po!


    THIS FORM IS NOT FOR SALE. REPRODUCTION IS ALLOWED.
    THIS CAN ALSO BE DOWNLOADED THROUGH THE OMBUDSMAN WEBSITE AT www.ombudsman.gov.ph

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