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

mm/dd/yyyy
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* 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.

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

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

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

T