Exit DOH - Pasco Customer Satisfaction Survey 1. Page 1 Question Title * 1. Date of survey Survey Date Date Question Title * 2. How did you hear about us? Word of mouth Returning client Twitter/Next Door/Social Media Booth or table at a local event Marketing ad (billboard, bus wrap, newspaper etc...) Other (please specify) Question Title * 3. Please choose location. Dade City Location Fasano Hudson Location Wesley Chapel Location Summit Location Question Title * 4. What was your visit for today? Immunizations WIC & Nutrition Breast and Cervical Cancer Program STD Clinic Healthy Start TB or Refugee Clinic Environmental Health Birth and Death Certificates Health Education HIV/AIDS Services Family Planning/Birth Control Epidemiology Business Office Other (please specify) Question Title * 5. Please rate the following statements. Strongly disagree Disagree Neither Agree nor Disagree Agree Strongly Agree I got the information or service that I needed. I got the information or service that I needed. Strongly disagree I got the information or service that I needed. Disagree I got the information or service that I needed. Neither Agree nor Disagree I got the information or service that I needed. Agree I got the information or service that I needed. Strongly Agree The service or information was clear and understandable. The service or information was clear and understandable. Strongly disagree The service or information was clear and understandable. Disagree The service or information was clear and understandable. Neither Agree nor Disagree The service or information was clear and understandable. Agree The service or information was clear and understandable. Strongly Agree The staff was friendly and polite. The staff was friendly and polite. Strongly disagree The staff was friendly and polite. Disagree The staff was friendly and polite. Neither Agree nor Disagree The staff was friendly and polite. Agree The staff was friendly and polite. Strongly Agree The staff was well informed. The staff was well informed. Strongly disagree The staff was well informed. Disagree The staff was well informed. Neither Agree nor Disagree The staff was well informed. Agree The staff was well informed. Strongly Agree All my questions were answered. All my questions were answered. Strongly disagree All my questions were answered. Disagree All my questions were answered. Neither Agree nor Disagree All my questions were answered. Agree All my questions were answered. Strongly Agree I was served in a timely manner. I was served in a timely manner. Strongly disagree I was served in a timely manner. Disagree I was served in a timely manner. Neither Agree nor Disagree I was served in a timely manner. Agree I was served in a timely manner. Strongly Agree Question Title * 6. Overall Very Dissatisfied Dissatisfied Neither Satisfied nor Dissatisfied Satisfied Very Satisfied How would you rate your satisfaction with the information or services you received? How would you rate your satisfaction with the information or services you received? Very Dissatisfied How would you rate your satisfaction with the information or services you received? Dissatisfied How would you rate your satisfaction with the information or services you received? Neither Satisfied nor Dissatisfied How would you rate your satisfaction with the information or services you received? Satisfied How would you rate your satisfaction with the information or services you received? Very Satisfied Question Title * 7. Tell us what we can do better. Question Title * 8. Comment on what we did well. This institution is an equal opportunity provider.Esta institución es un proveedor que ofrece igualdad de oportunidades. Question Title * 9. Has a staff member exceeded your expectations? Thank them by providing their name: Question Title * 10. Contact Information Name Address City/Town State/Province ZIP/Postal Code Email Address Phone Number Done
