FORM NO: FN 5.

1-2

ISSUE DATE: 2013 Jan 05

REVISION DATE: ---

REVISION NO.:

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CUSTOMER
How can we improve?

FEEDBACK

FORM

CUSTOMER FEEDBACK FORM

Date: Company: Personnel:
PRINT NAME SIGNATURE

Form No:

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

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

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

Non-Destructive Testing Quality Assurance Quality Control & Inspection

Heat Treatment Cold Galvanizing Compound

Is there any information about your Company you would like to share with CIMS?
YES NO

If yes, please provide details:

*Please Rate:
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

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Section 2 of 4

FORM NO: FN 5.1-2

ISSUE DATE: 2013 Jan 5

REVISION DATE: ---

REVISION NO.:

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CUSTOMER FEEDBACK FORM

CIMSLs 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:

YES

NO

_______________________________________ Managers Signature

____________________ Date

General/MD comments:

_______________________________________ MD/Managers Signature

____________________ Date

(NOTE: MDs signature required for complaints only)

HSEQ Department:
Was Corrective Action effectively implemented? Details: YES NO

______________________________________ HSEQ Coordinator

____________________ Date

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Section 4 of 4