What health dept, clinic, or office did you visit? What was the purpose of your visit? Was your wait time acceptable? YesNo (if no, please note why in comment box) Did you receive friendly and well-organized customer service? YesNo (if no, please note why in comment box) In the past 12 months, how many times have you visited a public health facility? 1-56-1010+ Please rate your overall experience: 10987654321 (1 being unsatisfied, 10 being completely satisfied) Comment Box (please include all suggestions, comments or complaints): May we contact you? If so, please provide the following: Your Name: Phone Number: - Email Address: