1. 請問您提出陳情的時間
(The date of your)：

2.請問您是用那一種方式陳情
(How did you present your petition)？

3.請問您多久後收到正式答覆
(How many days later did the formal answer reach you)？
（答31天以上者請續答第3-1題）
(in case more than 31 days, please continue the following 3-1）

3-1.請問有關機關是否先行通知您本案未能於30天內辦結的理由
(Have you ever been informed by the competent authority that your petition may take more than 30 days and its reasons)？

4.請問您是否一次向多個機關陳情同一事件
(Have you petitioned to several different authorities for the same case)？

5.請問您的問題解決了嗎
(Whether your problem has been resolved)？

6.請問您對於有關機關的答覆內容滿意嗎 (Did the answer from the competent authorities satisfy you)？
（答不滿意或非常不滿意者，請續答6-1題） (if your answer is unsatisfactory or very unsatisfactory, please continue the following 6-1）

6-1.請問您不滿意的理由
(Why you were unsatisfied？)
（可複選 ）
(You may tick more than one.）

7.請問您以前是否曾向本機關陳情 (Have you ever petitioned to this Administration before)？

8.請問您這次陳情是否針對以前曾陳情的相同事由再來陳情
(Did you petition this time for the same old case you had made before)？
(答是者請續答8-1題）
(If yes, please continue the following 8-1)