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Grundy County Health Department
Client Satisfaction Survey
11
Questions
BEGIN
HIPAA
Compliance
1
Date of Service
/
Date
Month
Day
Year
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2
Are you a Grundy County resident?
YES
NO
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3
What service did you receive?
Blood draw
Birth or death certificate
Flu shot
Health screening
Immunization
Notary
WIC
Other
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4
How would you rate the friendliness of the GCHD staff?
Was the staff courteous and respectful? Were your questions answered?
1
2
3
4
5
Not friendly
Very friendly
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5
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
4
5
Unsatisfactory
Excellent
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6
How would you rate the quality of the service you received?
Was the staff knowledgeable and professional?
1
2
3
4
5
Unsatisfactory
Excellent
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7
How would you rate the efficiency of the service you received?
Were you greeted quickly? Did you wait long for service?
1
2
3
4
5
Not efficient
Very efficient
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8
We welcome your comments!
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9
Would you like someone to follow up with you?
YES
NO
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10
Name
*
This field is required.
First Name
Last Name
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11
Phone Number
Area Code
Phone Number
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