Customer Satisfaction Survey

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* 1. Date:

Month/Day/Year

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* 2. Select the answer that best describes your experience from
1 (Strongly Disagree) to 5 (Strongly Agree).

  Strongly Disagree Disagree Neutral Agree Strongly Agree
1. My phone calls were returned within 24 hours.
2. The time I waited before seeing a staff person was reasonable.
3. Staff was knowledgeable about services in Women's Health Family Planning Clinic.
4. Staff was good about explaining the reason for this visit.
5. I was provided clear instructions on follow-up appointments.
6. I feel that my confidentiality was respected.
7. Staff was sensitive to my cultural and ethnic background.
8. The clinic exam rooms are clean and professional.
9. Women's Health Family Planning staff appearance was clean and professional.
10. I was treated respectfully by staff.
11. Overall, I am satisfied with the Women's Health Family Planning clinic/program.

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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. Sexual Orientation

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* 9. Race

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* 10. Primary Language

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* 11. Were you satisfied with the translation/interpretation services you received today?

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