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* 1. Time of Visit:

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* 2. Are you:

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* 3. What is your age?

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* 4. Which of the following best describes your racial or ethnic background?

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* 5. The Health Department is open from 8:00am-5:00pm.  Are the hours of operation convenient for you?

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* 6. Why did you choose the Health Department for your health care?  Please check all that apply.

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* 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 
Length of wait time
Quality of Care Provided 
Cleanliness of Building
Directional Signs in the Building

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* 8. During your visit do you feel that our staff treated you with respect?

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* 9. Have you ever accessed your Harnett County Health Department patient portal?

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* 10. What was the reason for your visit?

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* 11. How satisfied were you with the ease of making an appointment?

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* 12. Would you recommend the Harnett County Health Department to your family and friends?

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* 13. How satisfied were you with your visit?

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* 14. Did you use interpreter services today?

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* 15. How satisfied were you with the availability of interpreter services during the clinic visit?

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* 16. Rate your ability to understand the information provided by the nurse or provider today.

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* 17. Comments

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