Customer Satisfaction Survey

In order for the Douglas County Health Department to best serve you, please take a few minutes to share your opinion with us. The survey should take about 5 minutes.

Thank you!

Question Title

* 1. Date of Service or Visit to Douglas County Health Department (DCHD)

Date of Service or Visit

Date

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* 2. Your Zip Code

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* 3. What is your gender?

Male

Female

Transgender Male

Transgender Female

Other

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* 4. What is your age?

19 and under

20-24

25-34

35-44

45 and over

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* 5. What is your race/ethnicity?

White

Black

Asian

Hispanic/Latino

American Indian/Alaska Native

Native Hawai'ian/Pacific Islander

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* 6. Select the option that best describes the quality of service you received for each of the items listed below.

	Excellent	Good	Fair	Poor	Does Not Apply
Courtesy and helpfulness of staff	Courtesy and helpfulness of staff Excellent	Courtesy and helpfulness of staff Good	Courtesy and helpfulness of staff Fair	Courtesy and helpfulness of staff Poor	Courtesy and helpfulness of staff Does Not Apply
Staff were very knowledgeable about the services requested	Staff were very knowledgeable about the services requested Excellent	Staff were very knowledgeable about the services requested Good	Staff were very knowledgeable about the services requested Fair	Staff were very knowledgeable about the services requested Poor	Staff were very knowledgeable about the services requested Does Not Apply
Staff listened to my concerns and were able to answer questions to my satisfaction	Staff listened to my concerns and were able to answer questions to my satisfaction Excellent	Staff listened to my concerns and were able to answer questions to my satisfaction Good	Staff listened to my concerns and were able to answer questions to my satisfaction Fair	Staff listened to my concerns and were able to answer questions to my satisfaction Poor	Staff listened to my concerns and were able to answer questions to my satisfaction Does Not Apply
Overall quality of staff assistance	Overall quality of staff assistance Excellent	Overall quality of staff assistance Good	Overall quality of staff assistance Fair	Overall quality of staff assistance Poor	Overall quality of staff assistance Does Not Apply
Overall quality of service(s) received	Overall quality of service(s) received Excellent	Overall quality of service(s) received Good	Overall quality of service(s) received Fair	Overall quality of service(s) received Poor	Overall quality of service(s) received Does Not Apply

Question Title

* 7. Which service did you receive from Douglas County Health Department?

STD Services: clinic visit or spoke to a DCHD Investigator about an STD

Attended an STD Testing Event in the Community (e.g. at a library, community center, or event)

Contacted or Interviewed by DCHD Staff about a Communicable Disease (other than an STD)

Environmental Health/Retail Food - Operators

Environmental Health/Retail Food - Consumers

Environmental Health/Sanitation (e.g. Complaint, Pools, Wells)

Immunization Clinic

Birth/Death Certificate

Data Request

Lead Testing in the Home

Other Service