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* 1. Date of Your Visit

Date / Time

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* 2. Time of Your Visit

Date / Time

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* 3. Staff Member Name:

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* 4. Which Program/Clinic:

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* 5. Location

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* 6. How long did you wait to be seen?

0 minutes 60 minutes
i We adjusted the number you entered based on the slider’s scale.

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* 7. The time I waited for service was:

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* 8. The staff was friendly and helpful and answered my questions.

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* 9. I plan to come back to the Health Department for future services

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* 10. I would recommend the Health Department to my family and friends

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* 11. I would rate my service today as:

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* 12. What I liked BEST about my visit to the health department was...

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* 13. What I liked LEAST about my visit to the health department was...

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* 14. OPTIONAL: If you would like a supervisor to contact you about your comments, please include your contact information

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