Teton County Health Department - Customer Satisfaction Survey Question Title * 1. Date of Service (if you know it) Date / Time Date OK Question Title * 2. Program(s) Visited: If you visited more than one program, please click all that apply. Women, Infants, Children (WIC) Immunizations Lactation Consulting Tobacco Cessation Cancer Control Program Communicable Disease Car Seat Safety Program Healthy Tracks (Diabetes Prevention Program) Emergency Preparedness Maternal and Child Health Public Health Nurse Childhood Lead Poison Prevention Other (please specify) OK Question Title * 3. Health Department Building Yes No Not Applicable Was the building easy to find? Was the building easy to find? Yes Was the building easy to find? No Was the building easy to find? Not Applicable Was the office clean? Was the office clean? Yes Was the office clean? No Was the office clean? Not Applicable Were there parking spaces available? Were there parking spaces available? Yes Were there parking spaces available? No Were there parking spaces available? Not Applicable If assistance was needed upon entering the building, did you receive it? If assistance was needed upon entering the building, did you receive it? Yes If assistance was needed upon entering the building, did you receive it? No If assistance was needed upon entering the building, did you receive it? Not Applicable If you phones, was the phone system easy to use? If you phones, was the phone system easy to use? Yes If you phones, was the phone system easy to use? No If you phones, was the phone system easy to use? Not Applicable If no, why not? OK Question Title * 4. Service Yes No Not Applicable Was the you needed easy to find in the building? Was the you needed easy to find in the building? Yes Was the you needed easy to find in the building? No Was the you needed easy to find in the building? Not Applicable Was the waiting room comfortable? Was the waiting room comfortable? Yes Was the waiting room comfortable? No Was the waiting room comfortable? Not Applicable Was your waiting time appropriate? Was your waiting time appropriate? Yes Was your waiting time appropriate? No Was your waiting time appropriate? Not Applicable Did the office hours meet your needs? Did the office hours meet your needs? Yes Did the office hours meet your needs? No Did the office hours meet your needs? Not Applicable Did the service/program meet your needs? Did the service/program meet your needs? Yes Did the service/program meet your needs? No Did the service/program meet your needs? Not Applicable If no, why not? OK Question Title * 5. Employees/Staff Yes No Not Applicable Were staff knowledgeable about programs/services? Were staff knowledgeable about programs/services? Yes Were staff knowledgeable about programs/services? No Were staff knowledgeable about programs/services? Not Applicable Did staff have professional attitudes? Did staff have professional attitudes? Yes Did staff have professional attitudes? No Did staff have professional attitudes? Not Applicable Did staff have professional appearance? Did staff have professional appearance? Yes Did staff have professional appearance? No Did staff have professional appearance? Not Applicable Were staff friendly/polite? Were staff friendly/polite? Yes Were staff friendly/polite? No Were staff friendly/polite? Not Applicable Were staff helpful? Were staff helpful? Yes Were staff helpful? No Were staff helpful? Not Applicable Were staff punctual/on time? Were staff punctual/on time? Yes Were staff punctual/on time? No Were staff punctual/on time? Not Applicable If no, why not? OK Question Title * 6. We value your comments. Please tell us more about your visit. What did we do well? OK Question Title * 7. What can we improve? OK Question Title * 8. How did you hear about us? Brochure (flyer, pamphlet, notebook) Family/Friend Newspaper Phone book Radio TV School Internet Facebook Referral (healthcare provider, hospital, agency) Walk-In Other (please specify) OK DONE