Exit Please click DONE when finished to submit your responses. Thank you for taking time to help us better serve you! Question Title * 1. In which Zip Code do you live? Question Title * 2. Please tell us when you visited. Today Within the last week Within the last month More than one month ago Question Title * 3. What service(s) did you receive on that date from the Allegany County Health Department? Birth or Death Certificates Clinical Services (where you saw a doctor/nurse, such as Immunization, Cancer Screening, STI, Tobacco Cessation) Dental Services Health Insurance Application or Information Home Visiting Service - Senior Services Home Visiting Service- Child and Family Services Burning Permit or Food Permit Septic or Well Information Projects for Assistance in Transition from Homelessness (PATH) Continuum of Care (CoC) Maryland Community Criminal Justice Treatment Program (MCCJTP) State Care Coordination WIC or Nutrition Information Behavioral Health (Addiction- related services) Behavioral Health (Mental Health- related services) Behavioral Health (Prevention- related services, such as Naloxone) Other (please specify) Question Title * 4. How do you feel about the following: Strongly Disagree Disagree Unsure Agree Strongly Agree I was treated with respect and kindness I was treated with respect and kindness Strongly Disagree I was treated with respect and kindness Disagree I was treated with respect and kindness Unsure I was treated with respect and kindness Agree I was treated with respect and kindness Strongly Agree I was satisfied with the quality of services I received I was satisfied with the quality of services I received Strongly Disagree I was satisfied with the quality of services I received Disagree I was satisfied with the quality of services I received Unsure I was satisfied with the quality of services I received Agree I was satisfied with the quality of services I received Strongly Agree I feel that my needs have been met I feel that my needs have been met Strongly Disagree I feel that my needs have been met Disagree I feel that my needs have been met Unsure I feel that my needs have been met Agree I feel that my needs have been met Strongly Agree My wait time was acceptable My wait time was acceptable Strongly Disagree My wait time was acceptable Disagree My wait time was acceptable Unsure My wait time was acceptable Agree My wait time was acceptable Strongly Agree The person who assisted me seemed knowledgeable The person who assisted me seemed knowledgeable Strongly Disagree The person who assisted me seemed knowledgeable Disagree The person who assisted me seemed knowledgeable Unsure The person who assisted me seemed knowledgeable Agree The person who assisted me seemed knowledgeable Strongly Agree Question Title * 5. Did someone go above and beyond to assist you? Let us know. Question Title * 6. What could we have done better? Additional Comments: Question Title * 7. What is your overall rating of Allegany County Health Department OPTIONAL InformationYou do not have to provide this information. You will not be asked for your name or any identifying information. However, answering these questions will help us improve our services. Thank you for taking the time to complete this questionnaire.(Please click DONE at the bottom) Question Title * 8. What is your racial and ethnic identity? White Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Prefer not to answer Question Title * 9. What is your age ? Under 18 18-24 25-34 35-44 45-54 55-64 65+ Prefer not to answer Question Title * 10. What is your gender? Female Male Non-binary Prefer not to answer Self-describe below Question Title * 11. Household Income Under $15,000 Between $15,000 and $29,999 Between $30,000 and $49,999 Between $50,000 and $74,999 Between $75,000 and $99,999 Between $100,000 and $150,000 Over $150,000 Prefer not to answer Your feedback is anonymous. However, if you would like to contact us feel free to do so at: ACHD.planning@maryland.gov or by calling (301) 759-5000 Thank you for taking time to help us better serve you! Done
