Fill out all information. It will be held confidential and not released to any other organization without your permission.
Company Name:
Company Address:
Describe Company Products and/or Services:
Your Name:
Your Work Number:
Your E-mail:
Your Position/Title
Do you want your responses to be held in confidence from your company? (We would prefer to be able to show your management your reponses, but we will withold them if you desire it) YES NO
Do you want to remain anonymous? (We would prefer to be able to use your name when talking to your management) YES NO
Services you are interested in (check all that apply) Y2k Presentation to Management Y2k Evaluation & Suggestions Y2k Software Impact Assessment Y2k Software Repair Other:
How serious do you feel the Y2k Problem is for America? Of No Consequence Minimal Marginal Important Serious Catastrophic Don't Know
How serious do you feel the Y2k Problem is for your company? Of No Consequence Minimal Marginal Important Serious Catastrophic Don't Know
How serious do you think your managers feel the Y2k problem is? Of No Consequence Minimal Marginal Important Serious Catastrophic Don't Know
Does your organization have resources budgeted to prepare or fix the Y2k problem? YES NO Don't Know
What steps has your organization taken in response to the Y2k Problem?
What steps would you LIKE your organization to take in response to Y2k?
Does your company use automated payroll or automated invoicing/billing? YES NO Don't Know
Does your company use computer databases? YES NO Don't Know
Does your company use systems with embedded microprocessors? YES NO Don't Know
Does your company sell products with embedded microprocessors? YES NO Don't Know
Describe the types, uses, and numbers of computers used by your company:
Does your company use custom designed software? YES NO Don't Know If so, answer the following questions: What programming language was used: Do you have the Source Code? YES NO Don't Know Do you have current Documentation? YES NO Don't Know
You can include additional Comments or Information Below:
Type of Comment or Information: Complaint Problem Suggestion Praise
What about us do you want to comment on? Web Site Company Services Questionnaire Response (Other) Other:
Enter your comments in the space provided below:
