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Carroll County General Health District
Customer Satisfaction Survey
Your opinion matters to us!!
Please help us improve our services by completing the survey. Thank you very much for taking the time to complete the survey. We appreciate your input!!
*
1.
I received services on
(Required.)
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*
2.
What type of services received? (Mark all that apply)
(Required.)
Birth or Death Certificate
Car Seat
Pack N Play (Portable Crib)
Immunization
Clinic Services (Contraception, STD, Annual Exam)
CMH
Consultation
Bridges to Wellness
Diaper Bank
Permit
Inspection
If you received a Permit or Inspection please specify type
*
3.
Ease in getting services?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
4.
Hours of operation?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
5.
Locating the Health Department?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
6.
Upper Level Services?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
7.
Lower Level Services?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
8.
Time spent waiting?
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
9.
Friendly and respectful staff?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
10.
Helpful and knowledgeable staff?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
11.
Professional behavior and dress of staff?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
12.
Clean and neat facility?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
13.
Protecting your privacy?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
14.
Overall experience?
(Required.)
Very Unsatisfied
1 star
Dissatisfied
2 stars
Neutral
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
N/A
*
15.
Was this the first time receiving services from the Carroll County General Health District?
(Required.)
Yes
No
*
16.
How did you hear about the Carroll County General Health District?
(Required.)
Family Member
Friend
Social Media (Facebook, Instagram)
Website
Newspaper
Employer
Other (please specify)
17.
If you were unhappy with your services today, what could we have done better?
18.
Additional Comments
