Public Health Customer Comment Form

As an alternative, this form may be printed and mailed to: Public Information Officer, El Dorado County Public Health Department, 931 Spring Street, Placerville, CA 95667
Printer version [.pdf]

Customer Comment Form

How are we doing? Please take a few minutes to complete this form. Thank you!

Today's Date: Is this your first contact with the Department? Yes No

What type of service did you receive today?

Where did you receive services? Placerville South Lake Tahoe Other:

For questions below, please click on the button that applies —>	Yes	No	Unsure	N/A
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?
Would you like Public Health to provide any other services that were not available to you today?

Please provide your comments or suggestions:

Is there anything we should know about your family, your culture, or your beliefs that would help us provide better service to you?

Note: You have the right to receive free language assistance services at the Public Health Department.

How did you hear about the Public Health Department? (Please check all that apply)
A friend or family member told me about you
I was referred (please name the agency, school, doctor, etc., who referred you)
I found the number/address in a directory (please name the directory)
I saw or heard an advertisement (please describe)
Other (please describe)

How do you normally receive health information or advice?(Please check all that apply)

Family	Friends	Doctor/Health Professional
Books	Newspapers or Magazines	Radio
Television	Internet	Other

Do you regularly use the Internet?	Yes	No	Which site(s) for health information?
Do you regularly listen to the radio?	Yes	No	Which station(s)?
Do you regularly read the newspaper?	Yes	No	Which paper(s)?

Additional comments or suggestions?

Name (Optional):
Would you like someone from Public Health to contact you? Yes No
If yes, how? (e.g., phone, address, e-mail):

Verification Code:

As a security measure, each request must include a Verification Code.

Audio version for the visually impaired

Enter Verification Code shown above:

THANK YOU FOR COMPLETING THIS FORM. YOUR COMMENTS ARE VERY IMPORTANT TO US!

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Tuesday, January 29, 2008 1:13 PM