* 1. What day did you receive services from the Health Department?

mm/dd/yyyy
/
/
:

* 2. What service(s) did you receive?(check all that apply)

* 3. For each statement below please choose the answer that best describes how you feel about your visit.

  Strongly disagree Disagree Neither disagree nor agree Agree Strongly Agree
The staff members were respectful
The staff members were friendly
The person you needed to see was readily available
The person who assisted you was knowledgeable
I was satisfied with the services I received
I was satisfied with the time it took to receive my services

* 4. Did you receive the service/information/referral you needed?

* 5. How did you hear about the Champaign Health District's services? (Check all that apply)

* 6. Is there anything else you would like to tell us about your experience?

T