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Questionnaire template

Customer Complaint Form

Lets customers report a problem with a product or service, its impact, and whether and how they want a follow-up.

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Customer · Customer experience. All Customer templates

Questions in this template

The Problem

  1. We are sorry something went wrong. Please tell us what happened so that we can look into it and put it right.

  2. What is your complaint about?

    Choose one:

    • Product or service quality
    • Customer service
    • Billing or invoicing
    • A technical problem
    • Other

  3. What is the complaint about?

    Condition: Shown when Other is selected

    Open answer

  4. How serious is the problem for you?

    Choose one:

    • 1 - Minor
    • 2
    • 3
    • 4
    • 5 - Severe

  5. Please describe what happened.

    Open answer

  6. When did you first notice the problem?

    Choose one from a list:

    • Today
    • Within the past week
    • Within the past month
    • 1 to 6 months ago
    • More than 6 months ago

  7. Has this problem happened to you before?

    Choose one:

    • Yes
    • No

Impact

  1. How did the problem affect you? Select all that apply.

    Choose any that apply:

    • Inconvenience
    • Money lost
    • Time lost
    • Stress or upset
    • Other

  2. In what other way were you affected?

    Condition: Shown when Other is selected

    Open answer

  3. How often has the problem come back?

    Condition: Shown when the problem has happened before

    Choose one from a list:

    • A few times
    • Often
    • Every time I use the product or service

  4. How satisfied were you with the way we handled your earlier reports of this problem?

    Condition: Shown when the problem has happened before

    Choose one:

    • Very dissatisfied
    • Dissatisfied
    • Neutral
    • Satisfied
    • Very satisfied
    • I did not report it before

Contact Details (Optional)

  1. Leave your details only if you would like us to get back to you. We will use them solely to follow up on this complaint.

  2. Would you like us to contact you about this complaint?

    Choose one:

    • Yes, by email
    • Yes, by phone
    • No, a follow-up is not needed

  3. What is your name?

    Condition: Shown when a follow-up is wanted

    Open answer

  4. What email address should we use?

    Condition: Shown when email contact is chosen

    Open answer

  5. What phone number should we call?

    Condition: Shown when phone contact is chosen

    Open answer

Further Comments

  1. Is there anything else you would like to add, or any suggestion for how we could do better?

    Open answer