Public Health Customer Feedback Card

Region of Peel staff are proud to be Working for you. In our continued effort to provide quality customer service, we would like to hear your comments and/or suggestions regarding the service you received.
   
Date (YYYY/MM/DD)
Clinic Location:
150 Central Park Drive Bolton Fairview
Malton Meadowvale South Millway
Other (specify)
    
What was the purpose of your contact with the Region of Peel?
Breastfeeding Dental Immunization
Prenatal Healthy Sexuality Vaccine Distribution
Other (please Specify)    
 
 
Very
Dissatisfied
 Very
Satisfied
  1       5
Overall, how satisfied were you with the service you received?
Overall, how satisfied were you with the total amount of time it took to get the service you wanted, from the time you arrived at the clinic to the time you were ready to leave?
 
How much do you agree or disagree with the following statements about the service you received?
(Please check the number that best describes your opinion)
 
Strongly
Disagree
 Strongly
Agree
  1       5
Staff made a real effort to make sure I got what I needed
Staff cared about my situation
I got clear, accurate information
 
Did you get what you needed?
Yes No
 I got part of what I needed
 
If you wish to comment further on any of our services, please do so below.
 
 
Would you like a health department representative to contact you about your comments or any problems you had with the service?
Yes
 No
 
Name
Phone
E-Mail
 
Thank you for your valued feedback! This information is being collected pursuant to the Health Protection and Promotion Act, R.S.O. 1990, c. H. 7 and will be retained, used, disclosed and disposed of in accordance with all applicable municipal, federal and provincial laws and regulations governing the collection, retention, use, disclosure and disposal of information including the Municipal Freedom of Information and Protection of Privacy Act, R. S. O. 1990, c. M. 56 and the Personal Health Information Protection Act, 2004, S. O. 2004, c. 3. This information will used to plan and evaluate health programs and services. Any questions regarding this collection may be directed to the Medical Officer of Health, Peel Public Health, 7120 Hurontario Street, PO Box 667 RPO Streetsville, Mississauga, ON L5M 2C2, 905-791-7800.

Revised: Wednesday January 11 2012

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