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Grundy County Health Department
Client Satisfaction Survey
12
Questions
BEGIN
HIPAA
Compliance
1
Please verify that you are human
*
This field is required.
You'd be surprised at how many SPAM responses we get!
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2
Date of Service
/
Date
Month
Day
Year
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3
Are you a Grundy County resident?
YES
NO
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4
What service did you receive?
Blood draw
Immunization
WIC
Birth or death certificate
Flu shot
Notary
Education event (CPR, baby shower, etc.)
Other
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5
How would you rate the friendliness of the GCHD staff?
Was the staff courteous and respectful? Were your questions answered?
1
2
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5
Not friendly
Very friendly
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6
How would you rate the GCHD facility?
Was the facility clean and welcoming? Was everything in working order? Were the restrooms clean?
1
2
3
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5
Unsatisfactory
Excellent
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7
How would you rate the quality of the service you received?
Was the staff knowledgeable and professional?
1
2
3
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5
Unsatisfactory
Excellent
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8
How would you rate the efficiency of the service you received?
Were you greeted quickly? Did you wait long for service?
1
2
3
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5
Not efficient
Very efficient
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9
We welcome your comments or suggestions!
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10
Would you like to be entered in our quarterly drawing for a Hy-Vee gift card?
YES
NO
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11
Name
*
This field is required.
First Name
Last Name
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12
Phone Number
Area Code
Phone Number
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