1. Name (Optional)

2. Telephone Number (will be kept anonymous)

3. Email Address (Optional)

4. What is your Age Range?

5. What is your gender?

6. District

7. County

8. Subcounty

11. What type of service were you seeking?

12. If other, please specify the public service sought?

13. Please specify the public institution you visited e.g. Mulago National Referral Hospital.

15. Please describe any positive aspects of the service you experienced. (Provide a detailed explanation)

16. Please describe any negative aspects of the service you experienced. (Provide a detailed explanation)

17. Have you ever tried to raise a concern to a leader or authority before?

18. If yes, how did you do it?

20. Would you be interested in writing a letter on services in your community?

21. If yes, do you consent to your letter being uploaded and shared with the responsible institutions?

22. If yes above, please upload letter here. (Keep it focused on recent experience, be factual and not fictional, respectful and solution oriented)

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