Customer Satisfaction Survey

* 1. Indicate the date the survey was completed.

Month / Day / Year
/
/

* 2. Type of Visit

* 3. 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 24 hours.
2. I was satisfied with the translation/interpretation services I received.
3. I was escorted to my exam room within 20 minutes or less of my scheduled appointment time.
4. Staff was knowledgeable about TB.
5. Staff clearly explained the reason for my TB visit.
7. I was provided clear instructions on follow-up steps.
8. I feel that my confidentiality was respected.
9. Staff was sensitive to my cultural and ethnic background.
10. The TB clinic rooms were clean.
11. Staff members conducted themselves in a professional manner.
12. I was treated well by staff.
13. Overall, I am satisfied with the services I received in the TB clinic.

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

* 5. Zip Code

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

* 7. Ethnicity

* 8. Gender

* 9. Sexual Orientation

* 10. Race

* 11. Primary Language

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