Customer Satisfaction Survey

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* 1. Indicate the date the survey was completed.

Date

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* 2. Select the answer that best describes your experience from
1 (Strongly Disagree) to 5 (Strongly Agree), or leave blank if not applicable.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
1. Immunization Staff greeted me courteously upon arrival.
2. Staff made an effort to communicate with me in a manner that met my needs.
3. Wait time in the registration area (where I signed in) was acceptable.
4. Wait time from when I was registered to when I was called into the exam room was acceptable.
5.. The clinic hours were convenient for me.
6. The immunization clinic rooms were clean.
7. Staff took time to explain things to me and answered my questions.
8. I was treated with respect.
9. Staff tried to accommodate for any of my cultural, language, gender, sexual orientation and ability needs.
10.  Overall, I am satisfied with the services I received in the Immunization Clinic.

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* 3. What is the most important thing we can do to improve our services?

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* 4. Is there anyone you would like to recognize for their service?

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* 5. Zip Code

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* 6. How did you hear about Columbus Public Health Services?

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* 7. Race

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* 8. Ethnicity

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* 9. Gender

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* 10. Primary Language

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