Date of Visit Please use MM / DD / YYYY format. Time of Visit Morning (8:00-12:00) Afternoon (1:00-5:00) 1. Why did you choose the Harnett County Health Department? (Please fill in all which apply.) Recommended by a friend Cost Confidentiality/Privacy 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.)   Excellent Good Fair Poor Privacy provided 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? Yes   No 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 Maternity Clinic WIC/ Nutrition Services Immunization Clinic (Child) Immunization Clinic (Adult) Health Depart. Social Work Lab Health Education Family Planning Other 6. Would you recommend the Harnett County Health Department to your family and friends? Yes   No 7. Which of the following best describes your racial or ethnic background? Black Asian Hispanic American-Indian White Other 8. Are the clinic hours convenient for you? Yes   No If you answered No, what hours would have been better for you? 9. How satisfied were you with your visit? Very satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Completely dissatisfied 10. Did you use interpreter services today? Yes   No Comments:   THANKS FOR YOUR TIME!