City-Cowley County Health Department Satisfaction Survey

Client responses to QA question about recent clinic visit.

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* 1. Please tell us in which Health Department office you had your visit:

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* 2. Was this your first visit to the Health Department?

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* 3. What date did you visit the office?

Date / Time

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* 4. What is your age?

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* 5. How did you learn about the Health Department services?

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* 6. What was your visit for?

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* 7. Who was this visit for?

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* 8. Was the clinic staff friendly?

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* 9. Were your questions about your specific health issues answered clearly?

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* 10. Did the clinic staff explain how payment for services are determined?

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* 11. How were the charges for service handled?

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* 12. Do you rate the price of the service is a good value?

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* 13. If you were unable to pay in full was a low cost payment plan offered to you?

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* 14. Please rate the quality of the service you recieved.

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* 15. Are there additional services that you would like the Health Department to offer?

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* 16. Did the Health Department Staff encourage you to complete this survey or a paper survey during your visit?

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* 17. Do you recall the staff members that helped you during your visit?  If so please enter their name(s).

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* 18. Thank you for taking time to answer these questions.  Will you use the services of the Health Department again?

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* 19. Each month we award a $25 gift card to a randomly chosen person who has completed this City-Cowley County Health Department Client Satisfaction Survey.  If you would like to be entered into the drawing please provide us your contact information (Name, phone or email) below. (If box is left blank no entry will be made).Thank you!

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