* 1. Time of Visit

* 2. Are you:

* 3. What is your age?

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

* 5. The Health Department is open from 8:00am – 5:00pm. How do you feel about the hours of operations?

* 6. Why did you choose the Harnett County Health Department? Please check all that apply.

* 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

* 8. Were you treated with respect?

* 9. Was the care that you received today sensitive to your culture?

* 10. What was the reason for your visit?

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

* 12. Was this location convenient for you?

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

* 14. How satified were you with your visit?

* 15. Did you use interpreter services?

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

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

* 18. Comments

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