Forms • Grant County, KS • CivicEngage

Introduction

The Grant County Health Department is asking you to complete this survey so that we can gain a better understanding of what our community believes in regard to public health and in particular our local facility. For questions and or suggestions:
Please Call: 620-356-1545.

Health Department Knowledge

Do you know where Grant County Health Department is located?*

Yes

No

Is Grant County Health Department open through the lunch hour?*

Yes

No

Is an appointment necessary to obtain services at Grant County Health Department?*

Yes

No

Can anyone have laboratory testing done at a reduced rate through Grant County Health Department?*

Yes

No

Does Grant County Health Department serve only those people with a limited income?*

Yes

No

Do you know what a Healthy Start Visit is?*

Yes

No

Are you aware that Grant County Health Department has a Car Seat Program?*

Yes

No

All communicable disease investigations are conducted through Grant County Health Department?*

True

False

Family Planning applies only to females?*

True

False

Tuberculosis treatment following a positive TB skin test is done free of charge?*

True

False

Childhood immunizations are more important than teen and adult immunizations?*

True

False

To what age group is Grant County Health Department most beneficial?*

	Infants
	Children
	Teens

	Adults
	All Age Groups

Personal Information

How old are you?*

	Pre-Teen (10-13)
	Teen (14-18)
	Young Adult (19-25)

	Adult (26-60)
	Advanced (61+)

What is your gender?*

Male

Female

How long have you lived in Grant County?*

	Less than 1 Year
	1-5 Years
	6-10 Years
	11-20 Years

	20 + Years
	Lifetime Resident
	Do not live in Grant County

Have you utilized any of the services offered by Grant County Health Department?*

Yes

No

Are you current on your immunizations?*

Yes

No

Services

What services have you utilized at Grant County Health Department? Please check all that apply.*

If other, please list

Communication / Information

Have you contacted Grant County Health Department in the last year?*

Yes

No

Was your most recent contact conducted in person, over the phone, by mail, or over the Internet?*

Have you ever had difficulty contacting Grant County Health Department?*

Yes

No

Are you aware that you can contact Grant County Health Department through the Grant County Website.*

Yes

No

What is your preferred method of communication in regards to COMMUNITY health concerns? (This would be general information that we would need to share community wide)
Please choose one.
*

What method of communication would you prefer regarding your PERSONAL information? (This would be information that is unique to you regarding services you have received at our office)*

	Phone (land line)
	Cell Phone
	Text
	County Website

	E-mail
	Facebook
	Twitter
	Mail

* indicates required fields.

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