1. Name (Optional)

2. Telephone Number (will be kept anonymous)

3. Email Address (will be kept anonymous)

4. Age Range

18 - 24

25 - 34

35 - 49

50 +

5. Gender

6. District

7. County

8. Subcounty

9. Parish

10. When was the last time you sought a service at a public institution?

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.

14. On a scale of 0 to 10, (0 being very poor, 10 being excellent). How would you rate the overall quality of the service you received at the public institution?

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?

19. What was your level of satisfaction with the concern you raised?

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)