Local Health Department Name



Local Health Department NameCustomer Satisfaction SurveyThank you for choosing the Local Health Department Name. In order to continuously improve the services we provide our clients, we kindly ask that you complete the following survey. The survey will only take a few minutes of your time. The responses you provide will be confidential. No identifying information about you will be collected.If you have any questions about the survey, please contact:Contact NamePhone NumberEmail AddressWe thank you in advance for your valuable feedback. Instructions for Completing the SurveyFor each question please select the answer that best represents your response. When you are finished completing the survey, please return your survey to one of the drop boxes located at each reception area within the health department. Please tell us about your experience with the Local Health Department Name.During your most recent visit with the Local Health Department Name, what program(s)/service(s) did you receive? (please check all that apply)Dental Health VisitWomen, Infants, and Children (WIC)Child or Adolescent ImmunizationAdult ImmunizationTravel Immunization/ClinicWell Child/Adolescent VisitFamily Planning ServicesBreast and Cervical Cancer Control Program (BCCCP) ServicesMental Health VisitSTD/HIVBirth/Death Records Environmental Health PermitEnvironmental Health InspectionCar Seat InspectionOther, please specify:_______________________________________________Where did you learn about our available services?From a friend or family memberFrom a Health Department staff memberFrom a Health Department brochure or flyerOther, please specify: ________________________________________________Where did you receive your service(s)?Health Department OfficeHome VisitBy PhoneOther, please specify:_________________________________________________The following questions pertain to your experience scheduling the service(s) you received today. Please respond to each of the following questions by checking the box under ‘yes’ or ‘no’ as appropriate. YesNoWas the phone system easy to use?Did the staff answer the phone promptly?Were the staff courteous on the phone?The following statements pertain to the service(s) you received today.Please indicate if you agree or disagree with each of the following statements by circling the number under your response. If you disagree with any of the statements below, please help us understand how we can improve by providing a comment under question 9. Strongly DisagreeDisagreeSomewhat DisagreeSomewhat AgreeAgreeStrongly AgreeHealth Department staff were friendly.123456The service(s) I received were delivered promptly.123456Health Department staff were respectful. 123456The wait time for the service(s) I received was appropriate.123456Health Department staff were helpful.123456The services I received met my social, cultural, and/or special needs.123456Health Department staff took the time to listen to my concerns.123456Health Department staff understood my needs.123456The office hours met my needs. 123456Overall, I am satisfied with the service(s) I received today.123456I was able to get what I needed from Local Health Department Name today.123456I would recommend the Local Health Department Name to my friends and family. 123456Did Health Department staff give you information during today’s visit about other services for which you might be eligible?YesNoDid anyone provide outstanding service? If so, whom?What did we do well during your visit today?What can we improve? (Please be specific.)The following questions ask for basic demographic information. Your answers to these questions will not affect the services you receive in any way.What is your gender?MaleFemaleWhat is your current age?18-24 years old25-39 years old40-64 years old65 + years oldWhat is your race?White, Non-HispanicBlackHispanic or LatinoAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderTwo or more racesOtherWhat is the highest level of education you completed?Less than High SchoolHigh School graduateSome CollegeAssociate’s DegreeBachelor’s DegreeGraduate or Professional DegreeWhat is your total household income?Less than $19,000$20,000 to $34,000$35,000 to $49,000$50,000 to $64,000$65,000 to $79,000$80,000 or greaterHow many children under the age of 18 live in your household?01234 or more ................
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