Customer Satisfaction Survey

Question Title

* 1. Date of most recent service

Date

Question Title

* 2. What service did you most recently receive? (check one)

Adolescent Programs, e.g. BAHEC

Community Health Education Center (CHEC)

Emergency Medical Services (EMS)

Emergency Preparedness

Environmental Education and Business Assistance, e.g. Safe Shops or Green & Clean

Environmental Inspection, e.g. Mold, Lead, Asbestos, Carbon Monoxide

Guest of Homeless Shelter

Home Visit, e.g. Injury Prevention, Healthy Baby/Healthy Child, Asthma

Narcan Training/Services

Permit Inspection, e.g. Nail or Tanning salon, Tobacco Vendor, Body Art, Recycling

Received services from a BPHC Nurse, e.g. Foodborne Illness/Outbreak

Received Data, Data Analysis Results, or Technical Assistance

Received Services from a School-Based Health Center

Substance Use/Recovery Services

Tobacco Cessation

Violence Prevention/Trauma Services

Received Help with Health Insurance, e.g. MassHealth, Health Connector, Medicare

I received a service that is not listed above (please specify)

Question Title

* 3. Please give details about the type of service you received in question number two

Question Title

* 4. Where did you receive this service? (check one)

At my Home

At my Business

At my Workplace

Over the Phone

Over the Internet (e.g. Email, Website)

In the Community

Offices at 1010 Massachusetts Ave

Offices at 727 Massachusetts Ave

Offices at 725 Massachusetts Ave

Offices at 723 Massachusetts Ave

Southampton Shelter (112 Southampton St)

The Woods-Mullen Shelter (794 Massachusetts Ave)

Finland Building (774 Albany St)

Miranda Creamer Building (785 Albany St)

Community Health Education Center (860 Harrison Ave., #2)

South End Fitness Center (35 Northampton St)

Entre Familia (209 River St)

Transitions Treatment Program (201 River St)

Wyman Reentry (201 River Street)

Engagement Center (behind the 112 Southampton Street Shelter)

Other (please specify)

Question Title

* 5. How satisfied were you with this service? (check one)

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Question Title

* 6. What can we do to improve? (Optional)

Question Title

* 7. What are we doing well? (Optional)

Question Title

* 8. Would you recommend the service you received to another member of the community? (check one)

Yes

Question Title

* 9. What's your current zip code?

Question Title

* 10. If you would like to be contacted regarding this service, please provide us with your contact information.

Name

Phone Number

Email Address