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1. What was the Date of Service:

Date

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2. What is your current Zip Code?

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3. Where did you receive Trumbull County Combined Health District services or information?

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4. Gender Identification?

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5. Your current age?

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6. What is your race/ethnicity?

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7. What program(s), service(s), or information did you receive from the TCCHD?

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8. I was treated with Courtesy and Respect by the TCCHD Staff member who helped me?

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9. The TCCHD Staff member who helped me, was knowledgeable, competent, and friendly.

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10. I received help from the TCCHD Staff in a reasonable amount of time.

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11. Technical information was given to me in a way that was easy for me to understand.

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12. I am satisfied with the services, and information I received.

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13. I would recommend services/programs offered by the TCCHD to friends and family.

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14. Do you have any additional comments, suggestions, and (or) concerns, etc?

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