Date: Form No:: How Can We Improve?

FORM NO: FN 5.1-2

ISSUE DATE: 2013 Jan 05

REVISION DATE: ---

REVISION NO.:

CUSTOMER

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FEEDBACK

FORM

CUSTOMER FEEDBACK FORM How can we improve? Date:

Form No:

Company: Personnel: PRINT NAME

Do you have any Health, Safety, Environmental or Quality concerns regarding provision of our Products and Services?

SIGNATURE

Department: CIMS employee conducting survey: Products/Services Purchased:

INFORMATION SHARING: Other CIMS Products/Services you may require:

Is there any information about your Company you would like to share with CIMS?



Non-Destructive Testing

 Heat Treatment



Quality Assurance

 Cold Galvanizing Compound



Quality Control & Inspection

1

*Please Rate:

 YES

2

3

If yes, please provide details:

4

a) Quality of Products – were specifications met? b) Quality & Efficiency of Services c) HSE matters addressed adequately? d) Delivery e) Ordering and Billing f) The courtesy of our Staff 1 = unsatisfactory,

2 = average,

3 = good,

4 = above expectations

*SEE REVERSE SIDE FOR COMPLAINTS *SEE REVERSE SIDE FOR COMPLAINTS

Section 1 of 4

Section 2 of 4

 NO

FORM NO: FN 5.1-2

ISSUE DATE: 2013 Jan 5

REVISION DATE: ---

REVISION NO.:

CUSTOMER FEEDBACK FORM

---

CIMSL’s use only: COMPLAINTS: Manager comments:

Job/Project/Purchase Referenced: Root cause of complaint:

Details of complaints:

Proposed corrective action

Was customer informed of Corrective Action? Details:

_______________________________________ Manager’s Signature

 YES

 NO

____________________ Date

General/MD comments:

_______________________________________ MD/Manager’s Signature

____________________ Date

(NOTE: MD’s signature required for complaints only)

HSEQ Department: Was Corrective Action effectively implemented? Details:

______________________________________ HSEQ Coordinator

Section 3 of 4

Section 4 of 4

 YES

 NO

____________________ Date