Today I:

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* 1. Today I:

Reason for visit:

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* 2. Reason for visit:

Please rate us on the following:

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* 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
Privacy
Overall Service
At your visit today, did you get all of your questions answered?

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

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

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

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

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

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

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

Would you like to share any other information with us?

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

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