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Customer Satisfaction Survey

Thank you for giving us the opportunity to serve you better!

Please take a few moments to tell us about the quality of the service you have received recently. We appreciate your feedback and want to make sure we meet your needs and expectations.

1. What day did you contact us or receive our services / information? mm/dd/yyyy This question requires a valid date format of MM/DD/YYYY.

calendar

2. What is your Zip Code? ex. 43604 This question requires a valid number format.

3. What was the *Main* service / information that you received from us?

4. Which location did you visit for your shots?

Please enter an 'other' value for this selection.

4. Who was vaccinated today?Check all that apply

Adult(s)
Child(ren)

4. Please rate us on the following:

Space Cell	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	N/A
I was treated with courtesy and respect by the staff who helped me today	I was treated with courtesy and respect by the staff who helped me today: Strongly Disagree	I was treated with courtesy and respect by the staff who helped me today: Disagree	I was treated with courtesy and respect by the staff who helped me today: Neutral	I was treated with courtesy and respect by the staff who helped me today: Agree	I was treated with courtesy and respect by the staff who helped me today: Strongly Agree	I was treated with courtesy and respect by the staff who helped me today: N/A
Staff were professional, knowledgeable, and competent	Staff were professional, knowledgeable, and competent: Strongly Disagree	Staff were professional, knowledgeable, and competent: Disagree	Staff were professional, knowledgeable, and competent: Neutral	Staff were professional, knowledgeable, and competent: Agree	Staff were professional, knowledgeable, and competent: Strongly Agree	Staff were professional, knowledgeable, and competent: N/A
Services and information were received in a timely and efficient manner	Services and information were received in a timely and efficient manner: Strongly Disagree	Services and information were received in a timely and efficient manner: Disagree	Services and information were received in a timely and efficient manner: Neutral	Services and information were received in a timely and efficient manner: Agree	Services and information were received in a timely and efficient manner: Strongly Agree	Services and information were received in a timely and efficient manner: N/A
Overall I am pleased with my experience today	Overall I am pleased with my experience today: Strongly Disagree	Overall I am pleased with my experience today: Disagree	Overall I am pleased with my experience today: Neutral	Overall I am pleased with my experience today: Agree	Overall I am pleased with my experience today: Strongly Agree	Overall I am pleased with my experience today: N/A

5. How did you connect with us on this date?

Please enter an 'other' value for this selection.

6. How easy was it to find what you were looking for on our website?

	0	1	2	3	4	5	6	7	8	9	10
Very Difficult	0	1	2	3	4	5	6	7	8	9	10	Very Easy

6. What information was difficult to find?

6. Do you wish to be contacted about your recent experience?

7. Name: *This question is required.

7. Email: *This question is required. This question requires a valid email address.

7. Phone: *This question is required.

7. Please briefly describe your experience / request: *This question is required.

A TLCHD staff member will reach out to you soon, thank you for allowing us to serve you better.

7. How did you find out about our services?

8. Please let us know about anything else that may help us provide high quality service:

9. What language(s) do you speak at home?

English
Spanish
Arabic
Chinese
Japanese
Other (please specify): Please enter an 'other' value for this selection.

10. Gender:

11. Age:

12. Race:

13. Are you of Hispanic, Latino/a, or Spanish origin?

14. Are you of Arab ancestry/ethnic origin?(Arab, Egyptian, Iraqi, Jordanian, Lebanese, Middle Eastern, Moroccan, North African, Palestinian, Syrian)