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.

Survey Item	Scale
Poor	Good	Excellent
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5
[Item Description]	1	2	3	4	5