Customer Satisfaction Survey

In-home nursing or home care aide

Vaccinations (immunizations)/school & daycare audit

Sexually Transmitted Disease testing

Private well testing, permitting

Septic permitting

Food service consultation, license, inspection

Biometric screening

Pool/spa, tanning facility, tattooing facility consultation, license, inspection

Nuisance complaint

Radon consultation, testing

Nutritional/wellness program

Diabetes program

Senior Health Clinic

Other:

	Excellent	Good	Average	Needs Improvement	Poor
Politeness & respectfulness of staff	Politeness & respectfulness of staff Excellent	Politeness & respectfulness of staff Good	Politeness & respectfulness of staff Average	Politeness & respectfulness of staff Needs Improvement	Politeness & respectfulness of staff Poor
Services met your needs	Services met your needs Excellent	Services met your needs Good	Services met your needs Average	Services met your needs Needs Improvement	Services met your needs Poor
Staff response to questions	Staff response to questions Excellent	Staff response to questions Good	Staff response to questions Average	Staff response to questions Needs Improvement	Staff response to questions Poor
Staff communication to you	Staff communication to you Excellent	Staff communication to you Good	Staff communication to you Average	Staff communication to you Needs Improvement	Staff communication to you Poor
Wait time for service	Wait time for service Excellent	Wait time for service Good	Wait time for service Average	Wait time for service Needs Improvement	Wait time for service Poor
Overall quality of service	Overall quality of service Excellent	Overall quality of service Good	Overall quality of service Average	Overall quality of service Needs Improvement	Overall quality of service Poor

Yes

Not Applicable

If not, how can we improve?

Date

MM /

DD /

YYYY