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2. Please help us better meet your needs by telling us how we did today. Thank you! Martha Hall, Health Officer, Lenawee County Health Department
5. 1. Date*

   Please enter the date you received health department services.

7. 2. What services did you have today?*

   1. Immunization
   2. Family Planning /Reproductive Health
   3. Children's Special Healthcare Services
   4. Hearing/Vision
   5. STI/HIV
   6. Breast and Cervical Cancer Control (BCCCNP)
   7. WiseWoman
   8. Tobacco Reduction
   9. Food Services
   10. Water Supply/Sewage Disposal
   11. Environmental Health
   12. Other
9. If Other, please describe:
11. Please answer the following questions:
13. 3. Were you able to get the information you needed?

    1. Yes
    2. No
    3. Partially
15. 4. The courtesy of staff was...

    1. Excellent
    2. Satisfactory
    3. Unsatisfactory
17. 5. The quality of staff was...

    1. Excellent
    2. Satisfactory
    3. Unsatisfactory
19. 6. The promptness of services was...

    1. Excellent
    2. Satisfactory
    3. Unsatisfactory
21. 7. Based on my experience overall, I am...

    1. Extremely satisfied
    2. Somewhat satisfied
    3. Unsatisfied
23. 8. How can we improve our services?
25. 9. Do you have something that you would like to discuss with us?

    1. Yes
    2. No
27. If yes, please provide us with your name, phone number and email address and someone will contact you.
29. 10. Would you like to recognize a staff personal for exceptional service?

    1. Yes
    2. No
31. If yes, please enter staff name and any comments
33. 11. Comments
35. Thank you! We appreciate your feedback!
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37. 1. Receive an email copy of this form.
38. Email address

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39. Submit

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