Family Planning Client Satisfaction Survey

Please tell us how you feel about our services and staff. Your responses help us make improvements. The survey is anonymous. Thank you for your time.

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

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* 2. What was the date of your visit?

Date / Time

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* 3. Ease of getting care:

  Great Good OK Fair Poor N/A
Time between making appointment and being seen
Convenience of clinic hours 
Convenience of clinic location

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* 4. Wait time during visit:

  Great Good OK Fair Poor N/A
Time in waiting area
Time in exam room

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* 5. Front desk staff:

  Great! Good OK Fair Poor N/A
Courtesy of staff
Clearly explains registration process
Answers your questions

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* 6. Provider: (Physician, Physicians Assistant)

  Great! Good OK Fair Poor N/A
Courtesy of provider
Listens to you
Takes enough time with you
Clearly explains what you want to know
Clearly explains medication

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* 7. Registered Nurses

  Great! Good OK Fair Poor N/A
Courtesy of RN
Clearly explains what you need to know

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* 8. Payment

  Great Good OK Fair Poor N/A
Amount you are required to pay for service
Explanation of Title X Family Planning charges

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* 9. Did you provide proof of income during this visit?

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* 10. Did you provide any contribution or make payment to the Health Department for your service?

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* 11. Facility:

  Great Good OK Fair Poor N/A
Cleanliness of clinic
Ease of finding where to go
Comfort while waiting

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* 12. Confidentiality

  Great Good OK Fair Poor N/A
Keeping your personal information private

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

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

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* 15. Are there any comments or suggestions that would help improve our services that you would like to provide?

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