* 1. Date of Service

* 2. Reason for visit? (check all that apply)

* 3. How did you receive service?

* 4. Are the office hours convenient?

* 5. Were you satisfied with the information or service that you received?

* 6. Were you served in a timely manner?

* 7. Was the staff respectful and well informed?

* 8. Would you give the Health Department facilities a good rating? (cleanliness, signs, parking, etc.)

* 9. If you would like to be contacted to discuss any concerns, please provide contact information.

* 10. Comments/Suggestions

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