MMDHD Community Health Services Client Survey
Please share with us how you think we are doing with our services. Your input is greatly appreciated!
1. Location of service:
2. Date of service:
3. Time of appointment:
4. Length of wait:
0 - 15 min
16 - 30 min
More than 30 min
7. Type of appointment:
8. Times you have used Health Department services:
1 to 5 times
6 to 20 times
More than 20 times
9. Service provided today:
WIC - Women, Infants & Children
MSS/ISS - Maternal or Infant
Children's Special Health Care
Breast and Cervical Cancer Control
Early On Program
Other - please specify below:
Please rate the quality of our services in the following (Please provide comments at the end of the form.)
10. Health Department programs have made a postive difference for my child/me.
11. Health Department staff were friendly and respectful.
12. Health Department staff could answer my questions and gave me useful information.
13. When calling the Health Department, I can reach the staff when I need to.
14. The Health Department office or offsite clinic was easy for me to find.
15. I am satisfied with the service I received today.
16. How did you hear about our services?
17. Have you visited the health department website at www.mmdhd.org before?
18. How can we improve our services?
If you would like us to contact you regarding a concern you may have, please provide the following information:
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