Sandusky County Public Health Customer Satisfaction Survey Question Title * 1. When did you receive our services? Date Date Question Title * 2. Your Zip Code Question Title * 3. What was the main service or information you received from us? Birth & Death Records Food Safety Inspections / Plans / Permits Environmental Inspections / Licensing Infectious Disease Immunizations / Shots Reproductive Health & Wellness / Family Planning WIC Help Me Grow Nursing Services/ Home Visiting Health Education Emergency Preparedness Other (please specify) Question Title * 4. I was treated with courtesy and respect by the staff who helped me. Strongly Agree Agree Disagree Strongly Disagree Comment Question Title * 5. Staff were professional, knowledgeable, and competent. Strongly Agree Agree Disagree Strongly Disagree Comment Question Title * 6. Services and information were received in a timely and efficient manner. Strongly Agree Agree Disagree Strongly Disagree Comment Question Title * 7. I was treated in a way that was respectful of my race/ethnic background/culture. Strongly agree Agree Disagree Strongly disagree Question Title * 8. Additional Comments, Questions, Concerns: Question Title * 9. How did you find out about the Health Department's Services? Friends / Family Website Radio Doctor Social Media: Facebook, Twitter, etc. Newspaper Other (please specify) Question Title * 10. Gender Male Female Question Title * 11. Age Under 18 18-24 25-32 33-40 41-54 55-64 65 or over Question Title * 12. Race White Black / African American Asian American Indian Alaskan Native Other (please specify) Question Title * 13. Ethnicity: Hispanic / Latino Yes No Question Title * 14. What language(s) do you speak at home? English Spanish Arabic Chinese Japanese Other (please specify) Question Title * 15. What additional services or information would you like to see Sandusky County Public health provide to the public? Question Title * 16. If you would like to receive our quarterly newsletter, please provide an email address below Question Title * 17. If you would like to be contacted about your recent experience, please leave your information below: Name: Phone # or Email Done