Quality Scale Survey Template
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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.

Scale

Survey Item

P
o
o
r

E
x
c
e
l
l
e
n
t

Good

1.

[Item Description]

1

2

3

4

5

2.

[Item Description]

1

2

3

4

5

3.

[Item Description]

1

2

3

4

5

4.

[Item Description]

1

2

3

4

5

5.

[Item Description]

1

2

3

4

5

6.