* 1. Today I:

* 2. Reason for visit:

* 3. Please rate us on the following:

  Great Good Fair Poor
Wait Time
Total Visit Time
Friendliness of Staff
Treated with dignity by Staff
Treated with respect by Staff & Providers
Overall Service

* 4. At your visit today, did you get all of your questions answered?

* 5. Did Health Department staff explain things in a way that was easy for you to understand?

* 6. The Health Department is open Monday-Friday, 8AM-5PM.  Are these hours of operation sufficient to meet your needs?

* 7. If no, please check the hours that would meet your needs.  Check all that apply.

* 8. Would you like to share any other information with us?