Customer Satisfaction Survey

Your Opinion Matters!

Important note before completing the survey: under Florida law your survey response is considered public record. Any information you provide could be released in response to a public records request. If you would like to speak with someone about your customer service instead, please contact our Community Health & Performance Management Division at 727-824-6900 x8165. Para la encuesta en Español,por favor haga clic aquí: clic aqui

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1. Please tell us the name of the EMPLOYEE who provided excellent service today! (If you can't provide a name, please enter NA).

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2. Please provide the date that you received service.

Date:

Date

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3. Please select service(s) received:

ADAP

Admitting/Eligibility

Annual Exam

Birth Control/Family Planning

Breast and Cervical Cancer Screening

Dental

Environmental Health

General Information

Home Visiting (Healthy Start/Healthy Families/Nurse Family Partnership)

Immunizations

Lab/Blood Work

Maternity

Medical Records

Pediatric Clinic

Pregnancy Test

PrEP

Primary Care

Refugee Health

School Health Services

STD Clinic

TB Clinic

Triage Nurse/Test Results

Vasectomy

Vital Statistics (Birth and Death Certificates)

WIC

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4. Please select the location where you received service using the menu below.

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5. Please rate your overall satisfaction with the service received.

Very Satisfied

Satisfied

Neutral (Not Satisfied or Dissatisfied)

Dissatisfied

Very Dissatisfied

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6. Please rate your level of agreement with the following statements:

	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
a. I received the information or service that I needed.	a. I received the information or service that I needed. Strongly Agree	a. I received the information or service that I needed. Agree	a. I received the information or service that I needed. Neither Agree nor Disagree	a. I received the information or service that I needed. Disagree	a. I received the information or service that I needed. Strongly Disagree
b. I was served in a timely manner.	b. I was served in a timely manner. Strongly Agree	b. I was served in a timely manner. Agree	b. I was served in a timely manner. Neither Agree nor Disagree	b. I was served in a timely manner. Disagree	b. I was served in a timely manner. Strongly Disagree
c. I was treated with courtesy and respect.	c. I was treated with courtesy and respect. Strongly Agree	c. I was treated with courtesy and respect. Agree	c. I was treated with courtesy and respect. Neither Agree nor Disagree	c. I was treated with courtesy and respect. Disagree	c. I was treated with courtesy and respect. Strongly Disagree
d. Staff was friendly and polite.	d. Staff was friendly and polite. Strongly Agree	d. Staff was friendly and polite. Agree	d. Staff was friendly and polite. Neither Agree nor Disagree	d. Staff was friendly and polite. Disagree	d. Staff was friendly and polite. Strongly Disagree

If you were not satisfied with your service and you would like to speak to someone, please call our Community Health & Performance Management Division at: 727-568-8165 ext. 8165

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7. Please Rate your level of agreement with the following statements:

	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
I feel the staff at this organization understand and respect my cultural needs and preferences.	I feel the staff at this organization understand and respect my cultural needs and preferences. Strongly Agree	I feel the staff at this organization understand and respect my cultural needs and preferences. Agree	I feel the staff at this organization understand and respect my cultural needs and preferences. Neither Agree nor Disagree	I feel the staff at this organization understand and respect my cultural needs and preferences. Disagree	I feel the staff at this organization understand and respect my cultural needs and preferences. Strongly Disagree

Other (please *Cultural needs and preferences include racial, gender, sexual orientation, ethnicity, language, ability, religious/spiritual, age, social class, economic situation, and/or other cultural based needs and preferences as you see fit.

If you are willing, please share more details about your experience so that we may better serve you.specify)

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1. Please tell us the name of the EMPLOYEE who provided excellent service today! (If you can't provide a name, please enter NA).

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2. Please provide the date that you received service.

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3. Please select service(s) received:

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4. Please select the location where you received service using the menu below.

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5. Please rate your overall satisfaction with the service received.

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6. Please rate your level of agreement with the following statements:

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7. Please Rate your level of agreement with the following statements:

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8. Comments/other: If you would like to provide additional comments, please provide information in the space below: