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. Question Title * 1. Please tell us in which Health Department office you had your visit: Arkansas City Office Winfield Office Question Title * 2. What was the date of your visit? Date / Time Date Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 9. Did you provide proof of income during this visit? Yes No NA Question Title * 10. Did you provide any contribution or make payment to the Health Department for your service? Yes No Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 14. Do you recall the staff members that helped you during your visit? If so please enter their name(s). Question Title * 15. Are there any comments or suggestions that would help improve our services that you would like to provide? Done