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* 1. When did you receive our services?

Date

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* 2. Your Zip Code

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* 3. What was the main service or information you received from us?

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* 4. I was treated with courtesy and respect by the staff who helped me.

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* 5. Staff were professional, knowledgeable, and competent.

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* 6. Services and information were received in a timely and efficient manner.

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* 7. I was treated in a way that was respectful of my race/ethnic background/culture.

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* 8. Additional Comments, Questions, Concerns:

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* 9. How did you find out about the Health Department's Services?

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* 10. Gender

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* 11. Age

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* 12. Race

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* 13. Ethnicity: Hispanic / Latino

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* 14. What language(s) do you speak at home?

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* 15. What additional services or information would you like to see Sandusky County Public health provide to the public?

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* 16. If you would like to receive our quarterly newsletter, please provide an email address below

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* 17. If you would like to be contacted about your recent experience, please leave your information below:

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