West Central Health District Customer Comment Card Question Title * 1. Date of Your Visit Date / Time Date OK Question Title * 2. Time of Your Visit Date / Time Time AM/PM - AM PM OK Question Title * 3. Staff Member Name: OK Question Title * 4. Which Program/Clinic: OK Question Title * 5. Location District Office Chattahoochee Clay Crisp Dooly Harris Macon Muscogee/Columbus Marion Quitman Randolph Schley Stewart Sumter Talbot Taylor Webster OK Question Title * 6. How long did you wait to be seen? 0 minutes 60 minutes Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 7. The time I waited for service was: Unacceptable Somewhat Unacceptable Somewhat Acceptable Very Acceptable N/A Unacceptable Somewhat Unacceptable Somewhat Acceptable Very Acceptable N/A OK Question Title * 8. The staff was friendly and helpful and answered my questions. Yes No Comments: OK Question Title * 9. I plan to come back to the Health Department for future services Yes No Comments: OK Question Title * 10. I would recommend the Health Department to my family and friends Yes No Comments: OK Question Title * 11. I would rate my service today as: Dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied N/A Dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied N/A OK Question Title * 12. What I liked BEST about my visit to the health department was... OK Question Title * 13. What I liked LEAST about my visit to the health department was... OK Question Title * 14. OPTIONAL: If you would like a supervisor to contact you about your comments, please include your contact information Name Email Address Phone Number OK NEXT