Client Feedback Form (CF-1) (Rev. 4/2019) English
Massachusetts Department of Transitional Assistance
CLIENT FEEDBACK FORM
You can use this form to let DTA know about your experience. You can tell us about a positive or
negative experience, or suggest how DTA can improve services. We care about your feedback!
Check this box if you need help completing this form or if you wish to receive a follow-up
phone call about this form.
Please provide your contact information below so a DTA representative can respond to your feedback.
You do not have to give your name or your phone number if you do not want DTA to contact you.
Name:________________________________________________________________________
Agency ID:____________________________________________________________________
Date of your experience:__________________________________________________________
Best phone number to reach you:___________________________________________________
Topic Areas: Please check all that apply.
Customer Service. This can include:
Was a case manager exceptionally helpful to you?
Was your call not returned?
Benefit Access and EBT. This can include:
Did you enjoy using your EBT card to get into a local museum?
Did you not get an EBT card?
The decision about your benefits. This can include:
How have DTA benefits helped your family?
Do you disagree with the Department’s decision?
Access to other DTA services. This can include:
Did a reasonable accommodation for a disability help you access benefits?
Were you not provided a translator?
Other. This can include:
A positive or negative experience you had with DTA.
Suggestions for how DTA can improve your experience.
Please use the space below to tell us about your experience:
Important: This form is not an appeal (a request for a fair hearing)
of a decision DTA has made in your case.
DTA – Client Feedback
P.O. Box 120429
