Customer Satisfaction Survey

* 1. Date:

Month/Day/Year
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* 2. Select the answer that best describes your experience from
1 (Strongly Disagree) to 5 (Strongly Agree), or leave blank if not applicable.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
1. My phone calls were returned within 1 business day.
2. The clinic hours were convenient for me.
3. I was informed about what to expect during my visit today.
4. The clinic (lobby, exam rooms, and clinic restrooms) was clean.
5. Staff members were respectful of my sexual orientation.
6. I was escorted to my exam room either before or at the estimated time given to me on my pink slip.
7. Wait time for results was acceptable. (Note: Lab results take at least 1 hour.)
8. Sexual Health staff took time to answer any questions I had.
9. Staff members were friendly.
10. Staff members were respectful of my cultural background.
11. I feel that my healthcare provider listened to me. 
12. I received information that will help me make good decisions about my health.
13. My personal well-being was a priority to my healthcare providers.
14. I was provided clear instructions on follow up steps.
15. My needs were met today.
16. Overall, I am satisfied with the services I received in the clinic.

* 3. What is the most important thing we can do to improve our services?

* 4. How did you hear about Columbus Public Health Services?

* 5. Ethnicity:

* 6. Gender:

* 7. Sexual Orientation:

* 8. Your Zip Code:

* 9. Race:

* 10. Primary Language:

* 11. Were you satisfied with the interpretation services you received today?

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