Clinic Customer Satisfaction Survey Customer Satisfaction Thank you for choosing Kenton-Hardin Health Department. Please tell us how we can better serve you. The responses you provide will be confidential. Question Title * 1. Please provide the date you received service(s) Date Date Question Title * 2. During your visit what program(s)/service(s) did you receive? check all that apply Child Immunization Adult Immunization Well Child Family Planning Car Seat Inspection Dental Health Visit Help Me Grow Blood Lead Level Testing Travel Immunization/Clinic Adolescent Immunization STD/HIV Blood Pressure Check BCMH Other (please specify) Question Title * 3. Where did you learn about our services? From a friend or family member From Health Department staff From Health Department brochure or flyer Doctor's Office Women, Infants, & Children (WIC) School Media Sources (Radio,TV, Facebook, Internet, Newspaper) Other (please specify) Question Title * 4. Where did you receive your service(s)? Health Department Home Visit By Phone Off-Site Location (travel clinic) Other (please specify) Question Title * 5. Please respond to each of the following questions by checking 'yes' or 'no' Yes No I used the phone system to make an appointment (checked "No" skip to question 6) I used the phone system to make an appointment (checked "No" skip to question 6) Yes I used the phone system to make an appointment (checked "No" skip to question 6) No Was the phone system easy to use? Was the phone system easy to use? Yes Was the phone system easy to use? No Were staff courteous on the phone? Were staff courteous on the phone? Yes Were staff courteous on the phone? No Question Title * 6. Indicate which best describes how you feel (1-5) Strongly Disagree (1) Disagree (2) Neither Agree nor Disagree (3) Agree (4) Strongly Agree (5) The office hours met my needs The office hours met my needs Strongly Disagree (1) The office hours met my needs Disagree (2) The office hours met my needs Neither Agree nor Disagree (3) The office hours met my needs Agree (4) The office hours met my needs Strongly Agree (5) There was adequate parking There was adequate parking Strongly Disagree (1) There was adequate parking Disagree (2) There was adequate parking Neither Agree nor Disagree (3) There was adequate parking Agree (4) There was adequate parking Strongly Agree (5) Staff were friendly Staff were friendly Strongly Disagree (1) Staff were friendly Disagree (2) Staff were friendly Neither Agree nor Disagree (3) Staff were friendly Agree (4) Staff were friendly Strongly Agree (5) The wait time was appropriate The wait time was appropriate Strongly Disagree (1) The wait time was appropriate Disagree (2) The wait time was appropriate Neither Agree nor Disagree (3) The wait time was appropriate Agree (4) The wait time was appropriate Strongly Agree (5) Question Title * 7. Indicate which best describes how you feel (1-5) Strongly Disagree (1) Disagree (2) Neither (3) Agree (4) Strongly Agree (5) I understood the information I was given I understood the information I was given Strongly Disagree (1) I understood the information I was given Disagree (2) I understood the information I was given Neither (3) I understood the information I was given Agree (4) I understood the information I was given Strongly Agree (5) I was given privacy when financial/medical information was discussed I was given privacy when financial/medical information was discussed Strongly Disagree (1) I was given privacy when financial/medical information was discussed Disagree (2) I was given privacy when financial/medical information was discussed Neither (3) I was given privacy when financial/medical information was discussed Agree (4) I was given privacy when financial/medical information was discussed Strongly Agree (5) I would recommend the Kenton-Hardin Health Department to friends/family I would recommend the Kenton-Hardin Health Department to friends/family Strongly Disagree (1) I would recommend the Kenton-Hardin Health Department to friends/family Disagree (2) I would recommend the Kenton-Hardin Health Department to friends/family Neither (3) I would recommend the Kenton-Hardin Health Department to friends/family Agree (4) I would recommend the Kenton-Hardin Health Department to friends/family Strongly Agree (5) Overall, I am satisfied with the service(s) I received Overall, I am satisfied with the service(s) I received Strongly Disagree (1) Overall, I am satisfied with the service(s) I received Disagree (2) Overall, I am satisfied with the service(s) I received Neither (3) Overall, I am satisfied with the service(s) I received Agree (4) Overall, I am satisfied with the service(s) I received Strongly Agree (5) Question Title * 8. Was the facility clean? No Yes Question Title * 9. What can we improve? Question Title * 10. What did we do well during your visit? Page1 / 2 Next