GCS-Admin
DOH-Clay Customer Satisfaction Survey
Overall: How would you rate your satisfaction with the information or services you received?
Very Satisfied
Satisfied
Neither Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
I got the information or service that I needed. (Accessibility)
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
The service or information was clear and understandable. (Clarity)
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
The staff was friendly and polite. (Courtesy)
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
The staff was well informed. (Knowledge)
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
The staff was helpful. (Helpfulness)
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
I was served in a timely manner. (Timeliness)
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
Location where you received information or a service:
Green Cove Springs
Bear Run Clinic
Other (Click Next)
Specify Location where you received service:
Which program did you receive information or a service from?
W.I.C.
Clinical or Medical Services
Vital Statistics
Ryan White
Community Health
Emergency Preparedness
Environmental Health
Disease Prevention & Control
School Based Dental Sealant Program
Teen Zone
Immunizations
School Health Services
OD2A Paramedicine Program
Administrative Services (such as fiscal, budget, human resources, IT, facilities)
Other (Click Next)
Specify which program you received information or service from?
What was the date you received services?
Additional Comments
Do you wish to be contacted regarding your visit? (YOU WILL BE CONTACTED WITHIN 5 BUSINESS DAYS)
Yes
No
ARE YOU SURE YOU WISH TO BE CONTACTED? (YOU WILL BE CONTACTED WITHIN 5 BUSINESS DAYS)
Yes
No
Please leave your name, address, phone number or email address below. You will be contacted within 5 business days.