Please click DONE when finished to submit your responses. Thank you for taking time to help us better serve you!

*1.In which Zip Code do you live?(Required.)

*2.Please tell us when you visited.(Required.)

TodayWithin the last weekWithin the last monthMore than one month ago

*3.What service(s) did you receive on that date from the Allegany County Health Department?(Required.)

Birth or Death Certificates

Clinical Services (where you saw a doctor/nurse, such as Immunization, Cancer Screening, STI, Tobacco Cessation)

Reproductive Health Services

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)

*4.How do you feel about the following:(Required.)

Strongly Disagree

Disagree

Unsure

Agree

Strongly Agree

I was treated with respect and kindness

Strongly Disagree

Disagree

Unsure

Agree

Strongly Agree

I was satisfied with the quality of services I received

Strongly Disagree

Disagree

Unsure

Agree

Strongly Agree

I feel that my needs have been met

Strongly Disagree

Disagree

Unsure

Agree

Strongly Agree

My wait time was acceptable

Strongly Disagree

Disagree

Unsure

Agree

Strongly Agree

The person who assisted me seemed knowledgeable

Strongly Disagree

Disagree

Unsure

Agree

Strongly Agree

5.Did someone go above and beyond to assist you? Let us know.

6.What could we have done better? Additional Comments:

*7.What is your overall rating of Allegany County Health Department(Required.)

1 star

2 stars

3 stars

4 stars

5 stars

OPTIONAL Information

You 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)

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

9.What is your age ?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Prefer not to answer

10.What is your gender?

Female

Male

Non-binary

Prefer not to answer

Self-describe below

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!