Customer Satisfaction Survey

Question Title

* 1. Date of Service

Please enter the date of service.

Date

Question Title

* 2. I came in today for:

a vaccine

a health permit

lead testing

WIC

STI/STD testing

birth control

lab services: patient testing

lab services: water testing

health education

a birth certificate

a death certificate

physical and/or occupational therapy

Other:

Question Title

* 3. Service location:

Grover Beach

Paso Robles

San Luis Obispo

Oceano

Atascadero

Nipomo

Morro Bay

phone/text

Other:

Question Title

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

Customer Satisfaction Survey

Question Title

* 1. Date of Service

Question Title

* 2. I came in today for:

Question Title

* 3. Service location:

Question Title

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

Question Title

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

Question Title

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