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Customer Satisfaction Survey

Please help us improve by taking this short survey. Thank you!

1. Date of service received: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

2. Which services did you receive? *This question is required.

3. Please rate your satisfaction with your wait time: (0=Very dissatisfied, 10=Very satisfied) *This question is required.

0	1	2	3	4	5	6	7	8	9	10
0	1	2	3	4	5	6	7	8	9	10

4. How much do you agree with the following statements? *This question is required.

Space Cell	Strongly Agree	Agree	Neither Agree or Disagree	Disagree	Strongly Disagree
The service I needed was available.	The service I needed was available.: Strongly Agree	The service I needed was available.: Agree	The service I needed was available.: Neither Agree or Disagree	The service I needed was available.: Disagree	The service I needed was available.: Strongly Disagree
The staff was helpful.	The staff was helpful.: Strongly Agree	The staff was helpful.: Agree	The staff was helpful.: Neither Agree or Disagree	The staff was helpful.: Disagree	The staff was helpful.: Strongly Disagree
I received the information I needed.	I received the information I needed.: Strongly Agree	I received the information I needed.: Agree	I received the information I needed.: Neither Agree or Disagree	I received the information I needed.: Disagree	I received the information I needed.: Strongly Disagree
Staff was knowledgeable.	Staff was knowledgeable.: Strongly Agree	Staff was knowledgeable.: Agree	Staff was knowledgeable.: Neither Agree or Disagree	Staff was knowledgeable.: Disagree	Staff was knowledgeable.: Strongly Disagree
I was served in a timely manner.	I was served in a timely manner.: Strongly Agree	I was served in a timely manner.: Agree	I was served in a timely manner.: Neither Agree or Disagree	I was served in a timely manner.: Disagree	I was served in a timely manner.: Strongly Disagree
This service was beneficial to me.	This service was beneficial to me.: Strongly Agree	This service was beneficial to me.: Agree	This service was beneficial to me.: Neither Agree or Disagree	This service was beneficial to me.: Disagree	This service was beneficial to me.: Strongly Disagree

5. If you responded "Disagree" or "Strongly Disagree" please explain why:

5. How likely are you to recommend our services to a family/friend? (0=not at all, 10=highly recommend) *This question is required.

0	1	2	3	4	5	6	7	8	9	10
0	1	2	3	4	5	6	7	8	9	10

6. What did we do well? *This question is required.

7. How did you hear about our services at the Whitley County Health Department? *This question is required.

Please enter an 'other' value for this selection. * This question is required.

8. Would you like to be contacted by a staff member to discuss your responses? *This question is required.

9. If yes, please list your name and contact information.

Name
Phone Number
Email