SurveyMonkey Powered Online Survey

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* 1. Date of Service

Date / Time

Date

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* 2. What service was provided? (ex. Inspection, WIC Services, Carseat class, Birth/Death Certificate, Immunization, etc.).

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* 3. Was the staff helpful?

Yes

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* 4. Was the staff friendly?

Yes

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* 5. What does Defiance County Public Health do well?

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* 6. What can Defiance County Public Health do better?

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* 7. How did you hear about Defiance County Public Health service(s)?

Google Search

Social Media

Event

Referral

Other (please specify)

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* 8. How would you like to learn about Defiance County Public Health programs and services?

Quarterly Newsletters

Social Media

Billboard

Health fairs

Flyers and Pamphlets

Other (please specify)

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* 9. Please list any additional programs or services you would like to see offered by Defiance County Public Health?

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* 10. Please select gender of the person receiving services.

Male

Female

Transgender

Non-binary/Non-conforming

Prefer not to respond

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* 11. Please choose the race & ethnicity of the person receiving services (mark all that apply)

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

Not Hispanic or Latino

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* 12. Please select the age of the person receiving our service.

0-7

8-15

16-24

25-34

35-44

45-54

55-64

65+

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* 13. Please indicate how much you agree or disagree with the following statements.

	Strongely Agree	Agree	Neutral	Disagree	Strongly Disagree	N/A
I am happy with my overall experience	I am happy with my overall experience Strongely Agree	I am happy with my overall experience Agree	I am happy with my overall experience Neutral	I am happy with my overall experience Disagree	I am happy with my overall experience Strongly Disagree	I am happy with my overall experience N/A
I am satisfied with the services I received	I am satisfied with the services I received Strongely Agree	I am satisfied with the services I received Agree	I am satisfied with the services I received Neutral	I am satisfied with the services I received Disagree	I am satisfied with the services I received Strongly Disagree	I am satisfied with the services I received N/A
I thought the verbal instructions/advice were easy to understand	I thought the verbal instructions/advice were easy to understand Strongely Agree	I thought the verbal instructions/advice were easy to understand Agree	I thought the verbal instructions/advice were easy to understand Neutral	I thought the verbal instructions/advice were easy to understand Disagree	I thought the verbal instructions/advice were easy to understand Strongly Disagree	I thought the verbal instructions/advice were easy to understand N/A
My questions were answered	My questions were answered Strongely Agree	My questions were answered Agree	My questions were answered Neutral	My questions were answered Disagree	My questions were answered Strongly Disagree	My questions were answered N/A
I am likely to recommend Defiance County Public Health to family or friends	I am likely to recommend Defiance County Public Health to family or friends Strongely Agree	I am likely to recommend Defiance County Public Health to family or friends Agree	I am likely to recommend Defiance County Public Health to family or friends Neutral	I am likely to recommend Defiance County Public Health to family or friends Disagree	I am likely to recommend Defiance County Public Health to family or friends Strongly Disagree	I am likely to recommend Defiance County Public Health to family or friends N/A

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