Client Satisfaction Survey Please tell us how you feel about our services and staff. Your responses help us to make improvements. This survey is anonymous. Thank you for your time. OK Question Title * 1. Date of appointment: Date: Date OK Question Title * 2. Which location were you seen at today? Casper Natrona County Health Department Cheyenne Laramie County Health Department Gillette Reproductive Health Laramie Reproductive Health Northwest Wyoming Family Planning - Cody Clinic Northwest Wyoming Family Planning - Powell Clinic Reproductive Healthcare of the Big Horns Washakie Family Planning - Worland Clinic Washakie Family Planning - Greybull Clinic Washakie Family Planning - Thermopolis Clinic Western Wyoming Family Planning - Rock Springs OK Question Title * 3. What is your Gender? Female Male Choose not to answer Other (please specify) OK Question Title * 4. What is your age? 15-17 18-19 20-24 25-29 30-34 35-39 40-44 Over 44 OK Please rate how well we are doing in the following areas: OK Question Title * 5. Convenience of clinic location Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 6. Courtesy of front desk staff Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 7. Clearly explained registration process Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 8. Answered your questions Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 9. Courtesy of provider Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 10. Provider listened to you Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 11. Provider took enough time with you Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 12. Provider clearly explained what you wanted to know Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 13. Provider clearly explained medication Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 14. Courtesy of nurse Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 15. Nurse clearly explained what you want to know Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 16. Explained today's charges Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 17. How do you feel about the cost of your visit today Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 18. Staff respected privacy Great Good OK Fair Poor N/A Great Good OK Fair Poor N/A OK Question Title * 19. If you received a contraceptive method today, is it what you wanted? Yes No N/A If not, why? OK Question Title * 20. How did you hear about us? Friend Relative Partner Online Referral Other Please specify Referral/Other: OK Question Title * 21. What do you like best about our clinic? OK Question Title * 22. What do you like least about our clinic? OK Question Title * 23. What could we have done to make your visit better today? OK Question Title * 24. Would you recommend us to friends/family? Yes No OK Thank you for completing our survey! Please contact the Wyoming Health Council with any additional comments or concerns at: 307-439-2033 or gwilson@wyhc.org OK DONE