Customer Satisfaction Survey

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* 1. County Health Department or Facility in which survey was completed:

Please check how well you feel we are doing in the following areas:

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* 2. Ease of getting care:

	Great	Good	Neutral	Fair	Poor	Does Not Apply	No Response
Ability to make an appointment	Ability to make an appointment Great	Ability to make an appointment Good	Ability to make an appointment Neutral	Ability to make an appointment Fair	Ability to make an appointment Poor	Ability to make an appointment Does Not Apply	Ability to make an appointment No Response
Hours that the Health Department is open	Hours that the Health Department is open Great	Hours that the Health Department is open Good	Hours that the Health Department is open Neutral	Hours that the Health Department is open Fair	Hours that the Health Department is open Poor	Hours that the Health Department is open Does Not Apply	Hours that the Health Department is open No Response
Convenience of Health Department's location	Convenience of Health Department's location Great	Convenience of Health Department's location Good	Convenience of Health Department's location Neutral	Convenience of Health Department's location Fair	Convenience of Health Department's location Poor	Convenience of Health Department's location Does Not Apply	Convenience of Health Department's location No Response
Quick return on phone calls by clerical staff	Quick return on phone calls by clerical staff Great	Quick return on phone calls by clerical staff Good	Quick return on phone calls by clerical staff Neutral	Quick return on phone calls by clerical staff Fair	Quick return on phone calls by clerical staff Poor	Quick return on phone calls by clerical staff Does Not Apply	Quick return on phone calls by clerical staff No Response
Quick return on phone calls by nursing staff (please note that nursing phone calls are returned within 24 working hours of receipt of patient message)	Quick return on phone calls by nursing staff (please note that nursing phone calls are returned within 24 working hours of receipt of patient message) Great	Quick return on phone calls by nursing staff (please note that nursing phone calls are returned within 24 working hours of receipt of patient message) Good	Quick return on phone calls by nursing staff (please note that nursing phone calls are returned within 24 working hours of receipt of patient message) Neutral	Quick return on phone calls by nursing staff (please note that nursing phone calls are returned within 24 working hours of receipt of patient message) Fair	Quick return on phone calls by nursing staff (please note that nursing phone calls are returned within 24 working hours of receipt of patient message) Poor	Quick return on phone calls by nursing staff (please note that nursing phone calls are returned within 24 working hours of receipt of patient message) Does Not Apply	Quick return on phone calls by nursing staff (please note that nursing phone calls are returned within 24 working hours of receipt of patient message) No Response

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* 3. Waiting:

	Great	Good	Neutral	Fair	Poor	Does Not Apply	No Response
Time spent in waiting room	Time spent in waiting room Great	Time spent in waiting room Good	Time spent in waiting room Neutral	Time spent in waiting room Fair	Time spent in waiting room Poor	Time spent in waiting room Does Not Apply	Time spent in waiting room No Response
Time spent in exam room	Time spent in exam room Great	Time spent in exam room Good	Time spent in exam room Neutral	Time spent in exam room Fair	Time spent in exam room Poor	Time spent in exam room Does Not Apply	Time spent in exam room No Response

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* 4. Staff

	Great	Good	Neutral	Fair	Poor	Does Not Apply	No Response
Front desk staff were friendly and professional	Front desk staff were friendly and professional Great	Front desk staff were friendly and professional Good	Front desk staff were friendly and professional Neutral	Front desk staff were friendly and professional Fair	Front desk staff were friendly and professional Poor	Front desk staff were friendly and professional Does Not Apply	Front desk staff were friendly and professional No Response
Front desk staff greeted me quickly	Front desk staff greeted me quickly Great	Front desk staff greeted me quickly Good	Front desk staff greeted me quickly Neutral	Front desk staff greeted me quickly Fair	Front desk staff greeted me quickly Poor	Front desk staff greeted me quickly Does Not Apply	Front desk staff greeted me quickly No Response
Nursing staff were friendly and professional	Nursing staff were friendly and professional Great	Nursing staff were friendly and professional Good	Nursing staff were friendly and professional Neutral	Nursing staff were friendly and professional Fair	Nursing staff were friendly and professional Poor	Nursing staff were friendly and professional Does Not Apply	Nursing staff were friendly and professional No Response
Staff respected my privacy	Staff respected my privacy Great	Staff respected my privacy Good	Staff respected my privacy Neutral	Staff respected my privacy Fair	Staff respected my privacy Poor	Staff respected my privacy Does Not Apply	Staff respected my privacy No Response

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* 5. Healthcare:

	Great	Good	Neutral	Fair	Poor	Does Not Apply	No Response
I was given good information related to my health	I was given good information related to my health Great	I was given good information related to my health Good	I was given good information related to my health Neutral	I was given good information related to my health Fair	I was given good information related to my health Poor	I was given good information related to my health Does Not Apply	I was given good information related to my health No Response
I had adequate time to ask health questions during the visit	I had adequate time to ask health questions during the visit Great	I had adequate time to ask health questions during the visit Good	I had adequate time to ask health questions during the visit Neutral	I had adequate time to ask health questions during the visit Fair	I had adequate time to ask health questions during the visit Poor	I had adequate time to ask health questions during the visit Does Not Apply	I had adequate time to ask health questions during the visit No Response
I was happy with my healthcare	I was happy with my healthcare Great	I was happy with my healthcare Good	I was happy with my healthcare Neutral	I was happy with my healthcare Fair	I was happy with my healthcare Poor	I was happy with my healthcare Does Not Apply	I was happy with my healthcare No Response

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* 6. Payment:

	Great	Good	Neutral	Fair	Poor	Does Not Apply	No Response
Cashier was friendly and helpful	Cashier was friendly and helpful Great	Cashier was friendly and helpful Good	Cashier was friendly and helpful Neutral	Cashier was friendly and helpful Fair	Cashier was friendly and helpful Poor	Cashier was friendly and helpful Does Not Apply	Cashier was friendly and helpful No Response
Charges were explained clearly	Charges were explained clearly Great	Charges were explained clearly Good	Charges were explained clearly Neutral	Charges were explained clearly Fair	Charges were explained clearly Poor	Charges were explained clearly Does Not Apply	Charges were explained clearly No Response

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* 7. Facility:

	Great	Good	Neutral	Fair	Poor	Does Not Apply	No Response
Facility was neat and clean	Facility was neat and clean Great	Facility was neat and clean Good	Facility was neat and clean Neutral	Facility was neat and clean Fair	Facility was neat and clean Poor	Facility was neat and clean Does Not Apply	Facility was neat and clean No Response
Waiting room was comfortable	Waiting room was comfortable Great	Waiting room was comfortable Good	Waiting room was comfortable Neutral	Waiting room was comfortable Fair	Waiting room was comfortable Poor	Waiting room was comfortable Does Not Apply	Waiting room was comfortable No Response

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* 8. Overall:

	Great	Good	Neutral	Fair	Poor	Does Not Apply	No Response
Overall feeling of visit	Overall feeling of visit Great	Overall feeling of visit Good	Overall feeling of visit Neutral	Overall feeling of visit Fair	Overall feeling of visit Poor	Overall feeling of visit Does Not Apply	Overall feeling of visit No Response

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* 9. Reason for today's visit (check all that apply)

Women's Health (breast health, birth control, pap smear)

TB (test, medication)

Pregnancy Test

Immunization (vaccine, shot record)

Children's Health

STD/HIV (test, medication)

WIC Nutrition/Education

Dental

No Response

Other (please specify)

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* 10. How did you hear about this facility and the services we offer?

Internet/Website

Radio

Facebook/Twitter

Theater/Billboard Advertisement

Referred by a friend/relative

Other (please specify)

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* 11. Was your visit a walk-in visit or appointment?

Walk-in

Appointment

No Response

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* 12. Age

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* 13. Sex

Male

Female

No Response

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* 14. Ethnicity

Hispanic

Non-Hispanic

No Response

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* 15. Race

Asian

Black

Native American/Alaskan Native

Hawaiian/Pacific Islander

Multiracial

White

No Response

Other (please specify)

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* 16. How can we serve you better?

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* 17. Comments:

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* 18. Would you like someone from the clinic to contact you regarding your comments about your services today? If so, please provide your telephone number below.