Patient Satisfaction Survey
 

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.)

 
ExcellentGoodFairPoor
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!


307 W Cornelius Harnett Boulevard

Lillington, 27546
910-893-7550
910-814-4060 fax
webhth@harnett.org