Fayette County Public Health Customer Satisfaction Survey Question Title * 1. How likely is it that you would recommend FCPH to a friend or colleague? NOT AT ALL LIKELY EXTREMELY LIKELY 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 OK Question Title * 2. What was the main department you visited today to receive service? Birth or Death Records/Certificates (Vital Statistics) Food Safety Inspections, plan review, or license Sewage System or Private Water System, plans, permits or inspection Water Samples Nuisance complaint or animal bite Infectious disease reporting Immunizations or shots CMH (Children with Medical Handicaps) TB Testing WIC (Women, Infant, Children) Services HMG (Help Me Grow) Emergency Preparedness RHW (Reproductive Health and Wellness) Clinic Vivtrol Clinic Sports Physicals Safe Sitter Classes Fat Fighters/Rolling Rimples CHA (Community Health Assessment)/CHIP (Community Health Improvement Plan) Breastfeeding Car Seat Program Other (please specify) OK Question Title * 3. Overall, how satisfied or dissatisfied are you with FCPH? Very satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Very dissatisfied OK Question Title * 4. Where did you receive FCPH services? FCPH Office Community Event/Meeting Website Phone call Email Your home or property OK Question Title * 5. I was treated with courtesy and respect by FCPH staff. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 6. FCPH staff were professional, knowledgeable, and competent. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 7. Services and information were received in a timely and efficient manner. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 8. Overall, I am pleased with the services received. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 9. When did you receive services from FCPH In the last week More than a week ago but less than a month ago More than a month ago OK Question Title * 10. Do you have any other comments, questions, or concerns? OK Question Title * 11. What is your zip code? OK Question Title * 12. If you would like to be contacted about your experience, please leave your name and contact information below. Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number OK DONE