United States Coast Guard
Maritime Safety and Security Customer Satisfaction Report

Select Activity Type *
Select Local USCG Unit or Nearest Port *
Other Activity
First Name: Last Name:

Email: Phone Number:
Vessel or Facility Name:
Vessel or Facility Official Number:

Select Country of Registry (If applicable) Company Name
Company Position
* Required Fields
Based on the activity type selected above, please select the applicable box to the right. Perception of the Customer
  Strongly
Disagree		 Disagree Neutral Agree Strongly
Agree		 N/A
The purpose and process of the USCG activity was explained clearly
I was/we were treated with dignity and respect
Form(s) issued to me clearly identified the applicable regulation(s) for which I was cited as noncompliant
USCG activity results and any item(s) requiring further coordination were fully explained and mutually understood
USCG officials were professional and knowledgeable
Local ports and waterways are safe, secure, and clean
Homeport content (e.g., contact info, resources) is accessible and current
USCG officials were prompt with returning phone call(s), e-mail(s), and scheduling
Additional remarks for strongly disagreeing:
Additional remarks for strongly agreeing:


Suggestions for how we can serve you better:
  Yes No
Please indicate if you would like a USCG representative to contact you (If yes, please ensure that you provide your e-mail or telephone number at the top)
Best time to contact you

Thank you for taking time to complete this survey; we value your feedback in directly helping the USCG ensure the highest level of commitment and service to the maritime industry and public.

This is a voluntary survey form approved by OMB through 12/31/2009. OMB #1625-0080

MPS-FM-MPS-01 (02)