Customer Satisfaction Survey

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* 1. Indicate the date the survey was completed.

Month / Day / Year

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* 2. Select the answer that best describes your experience from
1 (Strongly Disagree) to 5 (Strongly Agree), or leave blank if not applicable.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
1. Staff greeted me courteously upon arrival.
2. Staff was sensitive to my cultural and ethnic background.
3. Wait time in the registration area (where you signed in) was acceptable.
4. Wait time in the screening/triage area (where you first spoke with a nurse) was acceptable.
5. Wait time in the exam room (where you were vaccinated) was acceptable.
6. The clinic hours were convenient for me.
7. My needs were met today.
8. The immunization clinic rooms were clean.
9. Staff took time to explain things to me and answered my questions.
10. The cost for services was reasonable.
11. Overall, I am satisfied with the services I received in the Immunization Clinic.

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* 3. What is the most important thing we can do to improve our services?

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* 4. Zip Code

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* 5. How did you hear about Columbus Public Health Services?

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* 6. Ethnicity

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* 7. Gender

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* 8. Race

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* 9. Primary Language

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