Patient Satisfaction Survey
1.
Time of Visit:
Morning (8:00am-12:00pm)
Afternoon (1:00pm-5:00pm
Extended Clinic (After 5:00pm)
2.
Are you:
Male
Female
Other
3.
What is your age?
Under 18
18-24
25-34
35-44
45-54
55-64
65-75
Over 75
4.
Which of the following best describes your racial or ethnic background?
Black
Hispanic
White
Asian
American Indian
Other
5.
Are the hours of operation convenient for you?
These hours are good for me
Health Department should be open earlier than 8:00am
Health Department should offer more clinics after 5:00pm
There should be extended hours.
Other (please specify)
6.
Why did you choose the Health Department for your health care? Please check all that apply.
Recommended by a friend
Cost
Confidentiality/Privacy
Convenient hours
Location
Quality of Care Provided
7.
Thinking about your visit, how would you rate the following (Fill in only one check box for each item).
Excellent
Good
Fair
Poor
Privacy provided
Excellent
Good
Fair
Poor
Length of wait time
Excellent
Good
Fair
Poor
Quality of Care provided
Excellent
Good
Fair
Poor
Cleanliness of building
Excellent
Good
Fair
Poor
Directional Signs in the building
Excellent
Good
Fair
Poor
8.
During your visit do you feel that our staff treated you with respect?
Yes
No
9.
Have you ever accessed your Harnett County Health Department patient portal?
Yes
No
10.
What was the reason for your visit?
Child Health Clinic
Immunization Child/Adult (circle)
WIC
Employee Health
Prenatal
Environmental Health
Division on Aging
Family Planning
STD
Social Work
Other (please specify)
11.
How satisfied were you with the ease of making an appointment?
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
12.
Would you recommend the Harnett County Health Department to your family and friends?
Yes
No
13.
How satisfied were you with your visit?
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
14.
Did you use interpreter services today?
Yes
No
15.
How satisfied were you with the availability of interpreter services during the clinic visit?
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
I did not use an interpreter
16.
Rate your ability to understand the information provided by the nurse or provider today.
Very Good
Good
Fair
Poor
Very Poor
17.
At any point did you feel like you were treated unfairly because of your race, ethnicity, sexual orientation, etc?
Yes
No
If yes, please explain
18.
Comments
Current Progress,
0 of 18 answered
