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2. Services Received:*

   Please mark the service(s) you have received from the Public Health Division.

   1. Women, Infants and Children (WIC)
   2. Home Visit or Nurse Office Visit
   3. Senior Clinic Services
   4. Immunizations
   5. Follow Along Program (FAP)
   6. Car seat Passenger Safety (CPS)
   7. Emergency Preparedness
   8. Community/PSE Work/SHIP Work
   9. Workplace Wellness (SHIP)
   10. Other
4. Other Service Received (please specify):
6. The person who scheduled my appointment was pleasant, respectful, and helpful.*

   1. Strongly Agree
   2. Agree
   3. No Opinion
   4. Disagree
   5. Strongly Disagree
   6. Does Not Apply
8. The wait time from check-in to when I was served was reasonable.*

   1. Strongly Agree
   2. Agree
   3. No Opinion
   4. Disagree
   5. Strongly Disagree
   6. Does Not Apply
10. The appointment was helpful and informative.*

    1. Strongly Agree
    2. Agree
    3. No Opinion
    4. Disagree
    5. Strongly Disagree
    6. Does Not Apply
12. I felt comfortable and respected during the appointment.*

    1. Strongly Agree
    2. Agree
    3. No Opinion
    4. Disagree
    5. Strongly Disagree
    6. Does Not Apply
14. I felt I received the services I needed to help me achieve my own health goals.*

    1. Strongly Agree
    2. Agree
    3. No Opinion
    4. Disagree
    5. Strongly Disagree
    6. Does Not Apply
16. I plan to return to use this service again in the future.*

    1. Strongly Agree
    2. Agree
    3. No Opinion
    4. Disagree
    5. Strongly Disagree
    6. Does Not Apply
18. If you do not plan to return to use this service again in the future, why?
20. Please note the type of transportation you used to get to Public Health:*

    1. Car
    2. Bus

    1. Walked
    2. Someone drove me

    1. Does not apply

    1. Other
22. Other type of transportation utilized:
24. Was there anything you really liked about the service you received?
26. What suggestions do you have to improve the services you received?
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

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