Patient Satisfaction Survey

Question Title

* 1. Time of Visit:

Morning (8:00am-12:00pm)

Afternoon (1:00pm-5:00pm

Extended Clinic (After 5:00pm)

Question Title

* 2. Are you:

Male

Female

Other

Question Title

* 3. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65-75

Over 75

Question Title

* 4. Which of the following best describes your racial or ethnic background?

Black

Hispanic

White

Asian

American Indian

Other

Question Title

* 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)

Question Title

* 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

Question Title

* 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	Privacy provided Excellent	Privacy provided Good	Privacy provided Fair	Privacy provided Poor
Length of wait time	Length of wait time Excellent	Length of wait time Good	Length of wait time Fair	Length of wait time Poor
Quality of Care provided	Quality of Care provided Excellent	Quality of Care provided Good	Quality of Care provided Fair	Quality of Care provided Poor
Cleanliness of building	Cleanliness of building Excellent	Cleanliness of building Good	Cleanliness of building Fair	Cleanliness of building Poor
Directional Signs in the building	Directional Signs in the building Excellent	Directional Signs in the building Good	Directional Signs in the building Fair	Directional Signs in the building Poor

Question Title

* 8. During your visit do you feel that our staff treated you with respect?

Yes

Question Title

* 9. Have you ever accessed your Harnett County Health Department patient portal?

Yes

Question Title

* 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)

Question Title

* 11. How satisfied were you with the ease of making an appointment?

Very satisfied

Satisfied

Neutral

Unsatisfied

Very unsatisfied

Question Title

* 12. Would you recommend the Harnett County Health Department to your family and friends?

Yes

Question Title

* 13. How satisfied were you with your visit?

Very satisfied

Satisfied

Neutral

Unsatisfied

Very unsatisfied

Question Title

* 14. Did you use interpreter services today?

Yes

Question Title

* 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

Question Title

* 16. Rate your ability to understand the information provided by the nurse or provider today.

Very Good

Good

Fair

Poor

Very Poor

Question Title

* 17. At any point did you feel like you were treated unfairly because of your race, ethnicity, sexual orientation, etc?

Yes

If yes, please explain

Patient Satisfaction Survey

Question Title

* 1. Time of Visit:

Question Title

* 2. Are you:

Question Title

* 3. What is your age?

Question Title

* 4. Which of the following best describes your racial or ethnic background?

Question Title

* 5. Are the hours of operation convenient for you?

Question Title

* 6. Why did you choose the Health Department for your health care? Please check all that apply.

Question Title

* 7. Thinking about your visit, how would you rate the following (Fill in only one check box for each item).

Question Title

* 8. During your visit do you feel that our staff treated you with respect?

Question Title

* 9. Have you ever accessed your Harnett County Health Department patient portal?

Question Title

* 10. What was the reason for your visit?

Question Title

* 11. How satisfied were you with the ease of making an appointment?

Question Title

* 12. Would you recommend the Harnett County Health Department to your family and friends?

Question Title

* 13. How satisfied were you with your visit?

Question Title

* 14. Did you use interpreter services today?

Question Title

* 15. How satisfied were you with the availability of interpreter services during the clinic visit?

Question Title

* 16. Rate your ability to understand the information provided by the nurse or provider today.

Question Title

* 17. At any point did you feel like you were treated unfairly because of your race, ethnicity, sexual orientation, etc?

Question Title

* 18. Comments