DHD#10 Client SurveyDHD#10 Client Survey

1. Location of service:

Location of service: Grayling

Kalkaska

Baldwin

Manistee

Ludington

Big Rapids

Lake City

White Cloud

Grant

Hart

Shelby

Cadillac

Other, please specify

2. Date of service:

	MM		DD		YYYY		HH		MM	AM/PM
	Date of service: Month	/	Day	/	Year		Hour	:	Minute	AM or PM

3. How long did you have to wait?

How long did you have to wait? no wait

1-9 minutes

10-19 minutes

20-29 minutes

30-39 minutes

Other, please specify

4. What was the first service you received during your visit?

What was the first service you received during your visit? Immunizations

WIC (Women, Infants and Children)

MIHP (Maternal Infant Health Program)

Family Planning

Breast and Cervical Cancer Control Screening

WiseWoman

Medicaid Application Assistance

Tencon

Children Special Health Care Services

Well Permit

Septic Permit

Food Service/Safety

Other, please specify

5. Please rate the quality of the first service you received:

	Great	Good	Average	Fair	Poor
Ability to get an appointment	*Please rate the quality of the first service you received: Ability to get an appointment Great	Ability to get an appointment Good	Ability to get an appointment Average	Ability to get an appointment Fair	Ability to get an appointment Poor
Hours the service is available at the health department	Hours the service is available at the health department Great	Hours the service is available at the health department Good	Hours the service is available at the health department Average	Hours the service is available at the health department Fair	Hours the service is available at the health department Poor
Prompt return on calls	Prompt return on calls Great	Prompt return on calls Good	Prompt return on calls Average	Prompt return on calls Fair	Prompt return on calls Poor
Time in waiting room	Time in waiting room Great	Time in waiting room Good	Time in waiting room Average	Time in waiting room Fair	Time in waiting room Poor
Staff listened to you	Staff listened to you Great	Staff listened to you Good	Staff listened to you Average	Staff listened to you Fair	Staff listened to you Poor
Staff took enough time with you	Staff took enough time with you Great	Staff took enough time with you Good	Staff took enough time with you Average	Staff took enough time with you Fair	Staff took enough time with you Poor
Staff gave helpful information	Staff gave helpful information Great	Staff gave helpful information Good	Staff gave helpful information Average	Staff gave helpful information Fair	Staff gave helpful information Poor
Staff was respectful to you	Staff was respectful to you Great	Staff was respectful to you Good	Staff was respectful to you Average	Staff was respectful to you Fair	Staff was respectful to you Poor
Staff answered your questions	Staff answered your questions Great	Staff answered your questions Good	Staff answered your questions Average	Staff answered your questions Fair	Staff answered your questions Poor
The overall quality of service	The overall quality of service Great	The overall quality of service Good	The overall quality of service Average	The overall quality of service Fair	The overall quality of service Poor

6. If you received another service during your visit, what was the second service?

If you received another service during your visit, what was the second service? I did not receive a second service during this visit

Immunizations

WIC (Women, Infants and Children)

MIHP (Maternal Infant Health Program)

Family Planning

Breast and Cervical Cancer Control Screening

WiseWoman

Medicaid Application Assistance

Tencon

Children Special Health Care Services

Well Permit

Septic Permit

Food Service/Safety

Other, please specify

7. If you received an additional service during this visit, please rate the quality of the second service:

	Great	Good	Average	Fair	Poor
Ability to get an appointment	If you received an additional service during this visit, please rate the quality of the second* service: Ability to get an appointment Great	Ability to get an appointment Good	Ability to get an appointment Average	Ability to get an appointment Fair	Ability to get an appointment Poor
Hours the service is available at the health department	Hours the service is available at the health department Great	Hours the service is available at the health department Good	Hours the service is available at the health department Average	Hours the service is available at the health department Fair	Hours the service is available at the health department Poor
Prompt return on calls	Prompt return on calls Great	Prompt return on calls Good	Prompt return on calls Average	Prompt return on calls Fair	Prompt return on calls Poor
Time in waiting room	Time in waiting room Great	Time in waiting room Good	Time in waiting room Average	Time in waiting room Fair	Time in waiting room Poor
Staff listened to you	Staff listened to you Great	Staff listened to you Good	Staff listened to you Average	Staff listened to you Fair	Staff listened to you Poor
Staff took enough time with you	Staff took enough time with you Great	Staff took enough time with you Good	Staff took enough time with you Average	Staff took enough time with you Fair	Staff took enough time with you Poor
Staff gave helpful information	Staff gave helpful information Great	Staff gave helpful information Good	Staff gave helpful information Average	Staff gave helpful information Fair	Staff gave helpful information Poor
Staff was respectful to you	Staff was respectful to you Great	Staff was respectful to you Good	Staff was respectful to you Average	Staff was respectful to you Fair	Staff was respectful to you Poor
Staff answered your questions	Staff answered your questions Great	Staff answered your questions Good	Staff answered your questions Average	Staff answered your questions Fair	Staff answered your questions Poor
The overall quality of service	The overall quality of service Great	The overall quality of service Good	The overall quality of service Average	The overall quality of service Fair	The overall quality of service Poor

8. If you received third service during your visit, what was the third service?

If you received third service during your visit, what was the third service? I did not receive a third service during this visit

Immunizations

WIC (Women, Infants and Children)

MIHP (Maternal Infant Health Program)

Family Planning

Breast and Cervical Cancer Control Screening

WiseWoman

Medicaid Application Assistance

Tencon

Children Special Health Care Services

Well Permit

Septic Permit

Food Service/Safety

Other, please specify

9. If you received a third service during this visit, please rate the quality of the third service.

	Great	Good	Average	Fair	Poor
Ability to get an appointment	If you received a third* service during this visit, please rate the quality of the third service. Ability to get an appointment Great	Ability to get an appointment Good	Ability to get an appointment Average	Ability to get an appointment Fair	Ability to get an appointment Poor
Hours the service is available at the health department	Hours the service is available at the health department Great	Hours the service is available at the health department Good	Hours the service is available at the health department Average	Hours the service is available at the health department Fair	Hours the service is available at the health department Poor
Prompt return on calls	Prompt return on calls Great	Prompt return on calls Good	Prompt return on calls Average	Prompt return on calls Fair	Prompt return on calls Poor
Time in waiting room	Time in waiting room Great	Time in waiting room Good	Time in waiting room Average	Time in waiting room Fair	Time in waiting room Poor
Staff listened to you	Staff listened to you Great	Staff listened to you Good	Staff listened to you Average	Staff listened to you Fair	Staff listened to you Poor
Staff took enough time with you	Staff took enough time with you Great	Staff took enough time with you Good	Staff took enough time with you Average	Staff took enough time with you Fair	Staff took enough time with you Poor
Staff gave helpful information	Staff gave helpful information Great	Staff gave helpful information Good	Staff gave helpful information Average	Staff gave helpful information Fair	Staff gave helpful information Poor
Staff was respectful to you	Staff was respectful to you Great	Staff was respectful to you Good	Staff was respectful to you Average	Staff was respectful to you Fair	Staff was respectful to you Poor
Staff answered your questions	Staff answered your questions Great	Staff answered your questions Good	Staff answered your questions Average	Staff answered your questions Fair	Staff answered your questions Poor
The overall quality of service	The overall quality of service Great	The overall quality of service Good	The overall quality of service Average	The overall quality of service Fair	The overall quality of service Poor

10. Please provide comments about what was helpful and how we can improve our services:

Please provide comments about what was helpful and how we can improve our services:

11. If you would like us to contact you regarding your answers on this survey, please provide your contact information.

If you would like us to contact you regarding your answers on this survey, please provide your contact information. Name
Phone number
Email Address