Quality Scale Survey Template

QUALITY SCALE SURVEY Name: Age: Gender: For each item identified below, circle the number to the right that best fits your judgment of its quality. Use the rating scale to select the quality number.

Scale

Survey Item

P o o r

E x c e l l e n t

Good

1.

[Item Description]

1

2

3

4

5

2.

[Item Description]

1

2

3

4

5

3.

[Item Description]

1

2

3

4

5

4.

[Item Description]

1

2

3

4

5

5.

[Item Description]

1

2

3

4

5

6.

[Item Description]

1

2

3

4

5

7.

[Item Description]

1

2

3

4

5

8.

[Item Description]

1

2

3

4

5

9.

[Item Description]

1

2

3

4

5

10.

[Item Description]

1

2

3

4

5

11.

[Item Description]

1

2

3

4

5

12.

[Item Description]

1

2

3

4

5