Please answer ALL questions

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for you time.

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* 1. Your Age

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* 2. Your Sex

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* 3. Your Race/Ethnicity

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* 4. Appointment or Walk-in?

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* 5. Name of Provider

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* 6. Ease of Getting Care: Ability to get in to be seen

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* 7. Ease of Getting Care: Hours Center is open

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* 8. Ease of Getting Care: Convenience of Center's location

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* 9. Ease of Getting Care: Prompt return on calls

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* 10. Waiting: Time in waiting room

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* 11. Waiting: Time in exam room

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* 12. Waiting: Waiting for tests to be performed

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* 13. Waiting: Waiting for tests results

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* 14. Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician Assistant, Nurse Practitioner - Listens to you

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* 15. Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician Assistant, Nurse Practitioner - Takes enough time with you

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* 16. Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician, Assistant, Nurse Practitioner - Explains what you want to know

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* 17. Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician Assistant, Nurse Practitioner - Gives you good advice and treatment

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* 18. Staff Provider: Nurses, Medical Assistants and Dental Assistants - Friendly and helpful to you

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* 19. Staff Provider: Nurses, Medical Assistants and Dental Assistants - Answers your questions

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* 20. Staff Provider: (Health Educator, Case Manager, Outreach-Eligibility, and all others) - Friendly and helpful to you

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* 21. Staff Provider: (Health Educator, Case Manager, Outreach-Eligibility, and all others) - Answers your questions

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* 22. Staff Provider: (Health Educator, Case Manager, Outreach-Eligibility, and all others) - Interpretation/Translation services

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* 23. Payment: What you pay

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* 24. Payment: Explanation of charges

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* 25. Payment: Collection of payment/money

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* 26. Facility: Neat and clean building

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* 27. Facility: Ease of finding where to go

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* 28. Facility: Comfort and Safety while waiting

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* 29. Facility: Privacy

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* 30. Confidentiality: Keeping my personal information private

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* 31. The likelihood of referring your friends and relatives to us

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* 32. Please provide any SPECIFIC DETAIL for any item rated 3 or below:

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* 33. Do you consider this center your regular source of
care?

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* 34. What do you like best about our center?

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* 35. What do you like least about our center?

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* 36. Do you have any suggestions for improvement?

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* 37. Would you like to be contacted? If yes, please provide information for desired contact method:

Name: ____________________________________________________________________

Email: _____________________________________________________________________

Telephone: _______________________________________________________________

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