Health Department Satisfaction Survey

Which Health Department location did you visit?

• Arkansas City
• Winfield

Was this your first visit to the Health Department?

• Yes
• No

What is your age?

• 18-24
• 25-34
• 35-44
• 45-54
• 55-64
• 65-74
• 75 or older

How did you hear about the Health Department's services?

• From a friend or relative
• Referral from another health provider
• Newspaper
• Radio
• Internet/social media
• Community event
• Other (please specify) Please enter an 'other' value for this selection.

What was the purpose of your visit?

• Immunization(s)
• WIC
• Reproductive Health Services
• Childcare Licensing
• Health Assessment/Kan-Be-Healthy Visit
• Women's Health Issues
• Environmental Permit
• Other (please specify) Please enter an 'other' value for this selection.

For whom was this visit?

• Myself
• My child
• Other (please specify) Please enter an 'other' value for this selection.

Were the clinic staff friendly?

• Yes
• No
• Not sure
• Other (please specify) Please enter an 'other' value for this selection.

Were your questions about specific health issues answered clearly?

• Yes
• No
• Not sure

Did the clinic staff explain how payment for services is determined?

• Yes
• No
• Not sure
• Other (please specify) Please enter an 'other' value for this selection.

How were the charges for services handled?

• Insurance paid for services
• I paid for services out of pocket
• Service was provided at no cost
• Other (please specify) Please enter an 'other' value for this selection.

How would you rate the value of the service based on price?

• Excellent - Fee for the product or service is the lowest in the area
• Average - Fee for the product or service is what I would have paid at another provider
• Poor - Fee for the product or service was a lot more than I expected
• Restrictive - I had to refuse service because the cost was more than I could afford

If you were unable to pay in full, was a low-cost payment plan offered to you?

• Yes
• No
• Not sure
• Other (please specify) Please enter an 'other' value for this selection.

Please rate the quality of service you received.

• Excellent
• Very Good
• Fair
• Poor
• Very Poor
• Other (please specify) Please enter an 'other' value for this selection.

Are there other services that you would like to see the Health Department provide?

• Yes (please specify below)
• No
• Not sure

Did the Health Department staff encourage you to complete this survey or a paper survey during your visit?

• Yes
• No
• Not Sure / Don't Remember

Will you use Health Department services again?

• Yes
• No
• Not sure
• Other (please specify) Please enter an 'other' value for this selection.