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Cuyahoga County Board of Health (CCBH) Customer Satisfaction Survey
Date you received service from CCBH:*
Category of service provided to you: (check all that apply)*
Screening
Consultation
Inspection
Investigation
Training
Treatment
Reporting
Education
Planning
Evaluation
Promotion
Surveillance
Survey
Referral
Sampling
Specific type of the service provided to you:*
Service was provided to you as: (check segments which best describe you)*
City Official
Family
General Public
Health Care Provider
Regulated Industry
School
Senior
Zip Code:*
Age Range :*
Under 5 years
5 to 9 years
10 to 14 years
15 to 19 years
20 to 24 years
25 to 29 years
30 to 34 years
35 to 39 years
40 to 44 years
45 to 49 years
50 to 54 years
55 to 59 years
60 to 64 years
65 to 69 years
70 to 74 years
75 to 79 years
80 to 84 years
85 years and over
Gender:*
Male
Female
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Some Other Race
Staff was knowledgeable:*
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
Staff was courteous:*
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
Staff was helpful:*
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
Hours of operation were adequate:*
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
Wait or response time was reasonable:*
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
Phone system met your needs:*
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
Web site met your needs:*
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
Overall quality of service:*
Poor
Fair
Average
Good
Excellent
Would recommend CCBH to others:*
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
How did you hear about CCBH?*
Friend or Family
Pamphlet
Phone Book
Newspaper
TV
Radio
Web
City Hall
Health Care Provider
Agency Referral
Other
General Comments:
Please copy the letters from the image to the field below.*
All fields marked with an asterisk (*) are mandatory.
Page viewed 338 times Last Modified: March 11, 2008
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