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* 1. Date of Service

Date

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* 2. I came in today for:

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* 3. On a scale from 1 to 5, how would you rate your recent experience with the Public Health Department?

  Disagree 1 2 3 4 Agree 5
I am happy with the service provided.
The information I received was clear and understandable.
This building and service area were clean and comfortable.
The office was easy to find.
I was able to access services at a date and time that worked for me.
Services were provided in a way that showed respect for my culture and values.
Services were provided in a language I understood.
I would recommend this service to a friend.

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* 4. Do you have any suggestions or comments? Please let us know what we did well or how we can improve: (optional)

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* 5. Would you like to discuss your experience in more detail? If so, please include how we can reach you: (optional)

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