SurveyMonkey Powered Online 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:

Arkansas City Office

Winfield Office

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* 2. What was the date of your visit?

Date / Time

Date

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* 3. Ease of getting care:

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

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* 4. Wait time during visit:

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

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* 5. Front desk staff:

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

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* 6. Provider: (Physician, Physicians Assistant)

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

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* 7. Registered Nurses

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

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* 8. Payment

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

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

Yes

No

NA

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

Yes

No

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* 11. Facility:

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

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* 12. Confidentiality

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

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

Yes

No

Not Certain / Don't Recall

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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?