Please tell us about visit today or the last time you were here. Your honest opinion will help us improve our services. Do not include your name. Your answers are confidential.

(1) At which school did you receive this survey? _________________________

HOW SATISFIED ARE YOU WITH:

Very Satisfied Somewhat Satisfied Somewhat Unsatisfied Not Satisfied Don’t Know
(2) Care you received from the School Nurse (Practitioner)? [] [] [] [] []
(3) How you were treated by the Medical Assistant? [] [] [] [] []
(4) The waiting time before your appointment? [] [] [] [] []
(5) Ability to make an appointment on the telephone? [] [] [] [] []
(6) Ability to make an appointment at the desk? [] [] [] [] []
(7) Time it took to complete your visit? [] [] [] [] []
(8) Your overall experience at the School Health Center? [] [] [] [] []
Yes No Uncertain
(9) Would you recommend the School Health Center to others? [] [] []


(10) What do you like best about the School Health Program?




(11) What other services/programs would you like the School Health Program to provide?




Thank you again for filling out this survey!