1.This questionnaire helps us understand how well we served you at XaaydaGa Dlaang Society / Haida Wellness Society. You can fill it out with our staff or on your own or email the Health Director at ayushi.shukla@haidawellness.org. Your feedback helps us improve our services.

Service provided:

Community Health Nurse

Doctors Clinic

Dental

Home & Community Care

Youth Centre

Mental Health

Cultural Programs

Patient Travel

Visiting Specialist

2.Name and phone number (to enter the monthly $50 draw)

3.I identify my gender as

4.I am between the ages of

18 years or less

19-44 years

45-64 years

65+ years

5.I am

A Skidegate Band Member

Indigenous, but not a Skidegate Band Member

Not Indigenous

6.Indicate how satisfied you are (1=lowest; 5=highest):

1

2

3

4

5

I am treated with respect when I receive services.

1

2

3

4

5

Program/ service is responsive to Haida culture, language and values.

1

2

3

4

5

I feel culturally safe and welcome.

1

2

3

4

5

Program/service meet my expectations.

1

2

3

4

5

I feel that my privacy and confidentiality are respected.

1

2

3

4

5

I would recommend this program/ service to others.

1

2

3

4

5

I gained a better understanding of my health

1

2

3

4

5

7.Indicate how satisfied you are with the services you recieved (1 = lowest; 5 = highest). If this does not apply, select N/A.

N/A

1

2

3

4

5

N/A

1

2

3

4

5

8.What I like about the program/service I received was

9.What I didn’t like about the program/ service I received was

10.I would like to learn more about...

11.Other comments