JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Pike County General Health District Customer Satisfaction Survey
We would love to hear your thoughts or feedback on how we can improve your experience!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
What was the date of your visit at PCGHD?
*
MM
/
DD
/
YYYY
What services did you receive on the date of your visit?
*
Death/Birth Certificates
Immunizations
TB Test/Reading
Shot Records
Pregnancy Test
Head Lice Check
Education
Bureau of Children with Medical Handicaps (BCMH)
HIV Testing
Public Health Nuisance Information
Septic Installation/On-site
Septic Permit
Sewage Certification
Land Split
Food Safety/Licensing/Plans/Permits
Campground/Pool/Tattoo Licensing
Safe Community Grant Education
Ohio Buckles Buckeyes Education (Car seat Program)
Emergency Response Education
Required
How was the quality of the services you received today?
*
Exceptional
Satisfactory
Unsatisfactory
Poor
Neutral
Were you treated with respect and courtesy from the PCGHD staff?
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The staff at PCGHD was professional, knowledgeable, and competent about my situation.
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
My situation was handled in a timely and efficient manner.
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Overall, were you pleased with the services you received here at the PCGHD today?
*
Yes
No
If “No”, please explain below:
Your answer
If you would like to be contacted about your experience today, please leave your name along with phone number or email.
Your answer
How did you hear about the services that are available at PCGHD?
*
Friends/Family
Internet
Radio
Television
Social Media Outlets (Facebook, Instagram, etc.)
Newspaper
Doctor
Other
Required
Would you return to PCGHD for services?
*
Yes
No
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report