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Coshocton Public Health District's Customer Experience Survey

Please take a few minutes to provide feedback on your recent experience with Coshocton Public Health District. We aspire to be the recognized leader in community health. Through the use of innovative, proactive and collaborative approaches we will improve conditions of health equity and wellness for all citizens of Coshocton County and would appreciate your feedback as we continue to fulfill our vision to the community.

1. Current age of the client that received services today (or most recent)?

2. What is the race/ethnicity of the client that received services today (or most recent)?

Please enter an 'other' value for this selection.

3. What is your zip code?

4. How did you connect with us on this date (or your most recent) service?

Please enter an 'other' value for this selection.

5. Which service did you receive?

6. How would you rate your experience today (or your most recent experience)?

	Excellent	Above Average	Average	Below Average	Poor
	Response:
Staff member(s) was knowledgeable and professional.	Staff member(s) was knowledgeable and professional.: Response:: Excellent	Staff member(s) was knowledgeable and professional.: Response:: Above Average	Staff member(s) was knowledgeable and professional.: Response:: Average	Staff member(s) was knowledgeable and professional.: Response:: Below Average	Staff member(s) was knowledgeable and professional.: Response:: Poor
Staff member(s) appears interested and involved in his/her work.	Staff member(s) appears interested and involved in his/her work.: Response:: Excellent	Staff member(s) appears interested and involved in his/her work.: Response:: Above Average	Staff member(s) appears interested and involved in his/her work.: Response:: Average	Staff member(s) appears interested and involved in his/her work.: Response:: Below Average	Staff member(s) appears interested and involved in his/her work.: Response:: Poor
Staff member(s) was courteous and attentive.	Staff member(s) was courteous and attentive.: Response:: Excellent	Staff member(s) was courteous and attentive.: Response:: Above Average	Staff member(s) was courteous and attentive.: Response:: Average	Staff member(s) was courteous and attentive.: Response:: Below Average	Staff member(s) was courteous and attentive.: Response:: Poor
Staff member(s) treated you with respect.	Staff member(s) treated you with respect. : Response:: Excellent	Staff member(s) treated you with respect. : Response:: Above Average	Staff member(s) treated you with respect. : Response:: Average	Staff member(s) treated you with respect. : Response:: Below Average	Staff member(s) treated you with respect. : Response:: Poor
Staff member(s) provided services in a non-discriminatory manner.	Staff member(s) provided services in a non-discriminatory manner.: Response:: Excellent	Staff member(s) provided services in a non-discriminatory manner.: Response:: Above Average	Staff member(s) provided services in a non-discriminatory manner.: Response:: Average	Staff member(s) provided services in a non-discriminatory manner.: Response:: Below Average	Staff member(s) provided services in a non-discriminatory manner.: Response:: Poor
Staff member(s) answered your questions, problems and/or concerns.	Staff member(s) answered your questions, problems and/or concerns. : Response:: Excellent	Staff member(s) answered your questions, problems and/or concerns. : Response:: Above Average	Staff member(s) answered your questions, problems and/or concerns. : Response:: Average	Staff member(s) answered your questions, problems and/or concerns. : Response:: Below Average	Staff member(s) answered your questions, problems and/or concerns. : Response:: Poor
Education that was provided by staff member.	Education that was provided by staff member.: Response:: Excellent	Education that was provided by staff member.: Response:: Above Average	Education that was provided by staff member.: Response:: Average	Education that was provided by staff member.: Response:: Below Average	Education that was provided by staff member.: Response:: Poor
Cleanliness of Health Department.	Cleanliness of Health Department.: Response:: Excellent	Cleanliness of Health Department.: Response:: Above Average	Cleanliness of Health Department.: Response:: Average	Cleanliness of Health Department.: Response:: Below Average	Cleanliness of Health Department.: Response:: Poor
All things considered, how was your overall service you were provided.	All things considered, how was your overall service you were provided. : Response:: Excellent	All things considered, how was your overall service you were provided. : Response:: Above Average	All things considered, how was your overall service you were provided. : Response:: Average	All things considered, how was your overall service you were provided. : Response:: Below Average	All things considered, how was your overall service you were provided. : Response:: Poor

7. How can we better serve you?

8. Where do you go for news and health information?

9. If you wish to be contacted about your recent experience please provide below your: name, phone number, and email address.