Customer Satisfaction Survey

This survey is to help us serve you better. We are listening! This survey will be returned to the Deputy Health Commissioner.

Question Title

* 1. During your most recent visit at Logan County Health District, what service(s) did you receive? (please check all that apply)

Birth/Death Records

WIC

Nursing - Immunizations, TB test, health information, etc

Environmental Health - sewage, water, food, permits/licenses, plumbing, etc

Other (please specify)

Question Title

* 2. How would you rate the following?:

	Poor	Fair	Good	Very Good	Exceptional
Office hours met your needs? If not, what hours would you like to see (write in the comment box below)?	Office hours met your needs? If not, what hours would you like to see (write in the comment box below)? Poor	Office hours met your needs? If not, what hours would you like to see (write in the comment box below)? Fair	Office hours met your needs? If not, what hours would you like to see (write in the comment box below)? Good	Office hours met your needs? If not, what hours would you like to see (write in the comment box below)? Very Good	Office hours met your needs? If not, what hours would you like to see (write in the comment box below)? Exceptional
Friendliness of front desk staff at window or first staff person who helped you?	Friendliness of front desk staff at window or first staff person who helped you? Poor	Friendliness of front desk staff at window or first staff person who helped you? Fair	Friendliness of front desk staff at window or first staff person who helped you? Good	Friendliness of front desk staff at window or first staff person who helped you? Very Good	Friendliness of front desk staff at window or first staff person who helped you? Exceptional
Health District Staff were respectful?	Health District Staff were respectful? Poor	Health District Staff were respectful? Fair	Health District Staff were respectful? Good	Health District Staff were respectful? Very Good	Health District Staff were respectful? Exceptional
Information or service that I needed was received?	Information or service that I needed was received? Poor	Information or service that I needed was received? Fair	Information or service that I needed was received? Good	Information or service that I needed was received? Very Good	Information or service that I needed was received? Exceptional
Information given was easy to understand?	Information given was easy to understand? Poor	Information given was easy to understand? Fair	Information given was easy to understand? Good	Information given was easy to understand? Very Good	Information given was easy to understand? Exceptional
The staff performed their work efficiently?	The staff performed their work efficiently? Poor	The staff performed their work efficiently? Fair	The staff performed their work efficiently? Good	The staff performed their work efficiently? Very Good	The staff performed their work efficiently? Exceptional
Overall, are you satisfied with the services received?	Overall, are you satisfied with the services received? Poor	Overall, are you satisfied with the services received? Fair	Overall, are you satisfied with the services received? Good	Overall, are you satisfied with the services received? Very Good	Overall, are you satisfied with the services received? Exceptional

Other (please specify)

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* 3. What did we do well during your visit today?

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* 4. What can we improve?

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* 5. Did anyone give outstanding service and if so whom?

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* 6. Is there anything else you would like to tell us?

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* 7. If you would be willing to serve as a resource to provide public input, please provide your contact information.

Name

Email Address

Phone Number