Please fill in all fields marked with a *
	Name of Facility	*
	Region
	District
	Date of Visit	During this weekOver 1 week but under 1 monthLast MonthLess than 3monthsover 3 months*
	Reason for visit	*
	Rate service received	ExcellentVery GoodGoodBadVery Bad*
	Comments
	Would you recommend this facility to others	YesNo*