| Is this your first contact with the Department? |
|
| What type of service did you receive today? |
|
| Where did you receive services? |
|
| Did you receive the service you requested? |
|
| Overall, were you satisfied with the service you received? |
|
| Was the service provided in a timely manner? |
|
| Was the service provider courteous and respectful? |
|
| If you contacted us by phone, was phone staff courteous and respectful? |
|
| If you visited us, was reception staff courteous and respectful? |
|
| |
|
Please provide your comments or suggestions:
|
|
|
Is there anything we should know about you, your culture or beliefs that would help us better serve you?
|
|
| Note: You have the right to receive free language assistance services at the Health Services Department. |
| Your Name (Optional): |
|
| Would you like our staff to contact you? |
|
| If yes, how? (e.g., phone, address, e-mail): |
|
| THANK YOU FOR COMPLETING THIS FORM. YOUR COMMENTS ARE VERY IMPORTANT TO US! |
|