Consumer/Community Satisfaction Survey Question Title * 1. Time of Visit Morning (8:00am-12:00pm) Afternoon (1:00pm-5:00pm) Question Title * 2. Are you: Male Female Question Title * 3. What is your age? Under 18 18-24 25-34 35-44 45-54 55-64 65-75 Over 75 Question Title * 4. Which of the following best describes your racial or ethnic background? Black White Hispanic American Indian Asian Other (please specify) Question Title * 5. The Health Department is open from 8:00am – 5:00pm. How do you feel about the hours of operations? These hours are good for me Health Department should be open earlier than 8:00am Health Department should close later than 5:00pm There should be extended hours (after 5pm) at least one day a week Other (please specify) Question Title * 6. Why did you choose the Harnett County Health Department? Please check all that apply. Recommended by a friend Cost Confidentiality/Privacy Convenient hours Location Quality of care provided Question Title * 7. Thinking about your visit, how would you rate the following (Fill in only one check box for each item). Excellent Good Fair Poor Privacy provided Privacy provided Excellent Privacy provided Good Privacy provided Fair Privacy provided Poor Length of wait time Length of wait time Excellent Length of wait time Good Length of wait time Fair Length of wait time Poor Quality of care provided Quality of care provided Excellent Quality of care provided Good Quality of care provided Fair Quality of care provided Poor Cleanliness of building Cleanliness of building Excellent Cleanliness of building Good Cleanliness of building Fair Cleanliness of building Poor Directional Signs in the building Directional Signs in the building Excellent Directional Signs in the building Good Directional Signs in the building Fair Directional Signs in the building Poor Question Title * 8. Were you treated with respect? Yes No Question Title * 9. Was the care that you received today sensitive to your culture? Yes No Question Title * 10. What was the reason for your visit? Child Health Clinic WIC Environmental Health Division on Aging Family Planning Immunization-Child Immunization-Adult Employee Health Prenatal STD Other (please specify) Question Title * 11. How satisfied were you with the ease of making an appointment? Very Satisfied Satisfied Neutral Unsatisfied Very unsatisfied Question Title * 12. Was this location convenient for you? Yes No Comment Question Title * 13. Would you recommend the Harnett County Health Department to your family and friends? Yes No Question Title * 14. How satified were you with your visit? Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied Question Title * 15. Did you use interpreter services? Yes No Question Title * 16. How satisfied were you with the availability of interpreter services during the clinic visit? Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied Question Title * 17. Rate your ability to understand the information provided by the nurse or provider today. Very Good Good Fair Poor Very Poor Question Title * 18. Comments Done