Patient Satisfaction Survey
Date of Visit
Please use MM / DD / YYYY format.
Time of Visit
1. Why did you choose the Harnett County Health Department?
(Please fill in all which apply.)
Recommended by a friend
No other place to go
Location / Convenient Hours
Quality of Care Provided
2. Thinking about your visit, how would you rate the following?
(Fill in only one box for each item.)
Length of wait time
Quality of care provided
Cleanliness of Health Department
Bulletin Board / Educational displays
Directional Signs in the building
3. Were you treated in a respectful and sensitive manner?
4. Today I:
Had a scheduled appointment
Was a walk-in
5. Today I was seen in the following areas
(Please check all that apply):
Adult Health Clinic
Communicable Disease Clinic
Child Health Clinic
WIC/ Nutrition Services
Immunization Clinic (Child)
Immunization Clinic (Adult)
Health Depart. Social Work
6. Would you recommend the Harnett County Health Department to your family and friends?
7. Which of the following best describes your racial or ethnic background?
8. Are the clinic hours convenient for you?
If you answered No, what hours would have been better for you?
9. How satisfied were you with your visit?
Neither satisfied nor dissatisfied
10. Did you use interpreter services today?
THANKS FOR YOUR TIME!
307 W Cornelius Harnett Boulevard