* 1. My age is:

* 2. I am

* 3. I live

* 4. Class Standing:

* 5. I have used Health Services in last year.

* 6. I have used the Counseling Center in the last year?

* 7. I was seen by a:

* 8. Access to Care:

  Poor Adequate Satisfactory Good Excellent
Ease of scheduling an appointment
Courtesy of persons involved in scheduling your appointment
Our helpfulness on the telephone

* 9. Has the new phone tree system been helpful?

* 10. During your visit:

  Poor Adequate Satisfactory Good Excellent
The Health Center/Counseling center was clean, neat, and professional
Friendliness/courtesy of staff in registration
Length of wait before going to an exam room
Friendliness/courtesy/concern of nursing staff
Wait time before you were seen by a Doctor/counselor

* 11. Your Care Provider:

  Poor Adequate Satisfactory Good Excellent
Friendliness/courtesy of provider
Explanations given to you about your problem or condition and treatment planned
Information given to you about follow up care
Degree to which care provider talked with you using words you can understand
Amount of time care provider spent with you

* 12. Personal Issues:

  Yes No
Do you feel our staff treated you respectfully?
Do you feel we were sensitive to your needs?
Do you feel we demonstrated concern for your privacy?
Do you feel confident in the care you received?
Are you overall satisfied with your care?

* 13. Please comment on your overall experience at the Health Center/Counseling Center:

* 14. Please list any suggestions you have for the Health Center/Counseling Center:

* 15. Would you like to contacted about your concerns? Please include contact information below.