Customer Satisfaction Survey

The following questions ask for information to help improve our programs and services.

1. When were you at the health department?

	MM		DD		YYYY
Date of Visit:	When were you at the health department? Date of Visit: Month	/	Day	/	Year

2. During your visit, what program did you use or service did you receive?

During your visit, what program did you use or service did you receive? Immunizations

TB Skin Testing

Dog Licensing

Well or Septic Permits

WIC

STD Testing or Treatment

Other (please specify)

3. Did you come alone?

Did you come alone? Yes

4. How long were you here?

How long were you here? Less than 15 minutes

15-30 minutes

31-60 minutes

More than 60 mintues

5. Were you given information about other services that might benefit you?

Were you given information about other services that might benefit you? Yes

6. Where did you learn about the program or service?

Where did you learn about the program or service? From a friend or family member

From a doctor/nurse/clinic

From a public health employee

From a realtor or contractor

Other (please specify)

7. Did anyone provide outstanding service?

Did anyone provide outstanding service? Yes

If yes, whom?

8. Please indicate if you agree or disagree with each of the following statements.

	Yes	No	Does Not Apply
The building was easy to find.	Please indicate if you agree or disagree with each of the following statements. The building was easy to find. Yes	The building was easy to find. No	The building was easy to find. Does Not Apply
Signs in the building were helpful.	Signs in the building were helpful. Yes	Signs in the building were helpful. No	Signs in the building were helpful. Does Not Apply
The building was clean.	The building was clean. Yes	The building was clean. No	The building was clean. Does Not Apply
The hours met my needs.	The hours met my needs. Yes	The hours met my needs. No	The hours met my needs. Does Not Apply
The wait time was appropriate.	The wait time was appropriate. Yes	The wait time was appropriate. No	The wait time was appropriate. Does Not Apply
The staff was easy to identify.	The staff was easy to identify. Yes	The staff was easy to identify. No	The staff was easy to identify. Does Not Apply
The staff was welcoming.	The staff was welcoming. Yes	The staff was welcoming. No	The staff was welcoming. Does Not Apply
The staff greeted me promptly.	The staff greeted me promptly. Yes	The staff greeted me promptly. No	The staff greeted me promptly. Does Not Apply
The staff was courteous and professional.	The staff was courteous and professional. Yes	The staff was courteous and professional. No	The staff was courteous and professional. Does Not Apply
The staff appeared knowledgeable and competent.	The staff appeared knowledgeable and competent. Yes	The staff appeared knowledgeable and competent. No	The staff appeared knowledgeable and competent. Does Not Apply
The staff was willing to help me.	The staff was willing to help me. Yes	The staff was willing to help me. No	The staff was willing to help me. Does Not Apply
The staff took the time to listen to me.	The staff took the time to listen to me. Yes	The staff took the time to listen to me. No	The staff took the time to listen to me. Does Not Apply
The staff did their best to help meet my needs.	The staff did their best to help meet my needs. Yes	The staff did their best to help meet my needs. No	The staff did their best to help meet my needs. Does Not Apply
I would recommend this program/service to others	I would recommend this program/service to others Yes	I would recommend this program/service to others No	I would recommend this program/service to others Does Not Apply

9. What can we improve? (Please be specific.)

What can we improve? (Please be specific.)