* 1. What Services did you receive? (More than one box may be checked)

* 2. Tell us about your experience.

  Strongly Agree Agree Disagree Strongly Disagree N/A
I was treated with courtesy and respect
I felt the quality of service was excellent
My wait time today was acceptable
The person who helped me today was knowledgeable and competent

* 3. How did you hear about the Fairfield Department of Health's services? (Please check as many as needed)

* 4. Are the hours of operation(8:00 a.m. to 4:00 p.m. and closed from 11:30 to 12:00 for lunch) convenient for you?

* 5. Do you feel that materials represent your race, language & ethnicity?

* 6. Please provide the Fairfield Department of Health with any comments about your experience with us. Thank you.