WPC Guest Survey Name Zip/Town Don't Know Yes Age 18-24 25-29 30-49 50-59 60 + Gender Male Female X Ethnicity Non Hispanic Hispanic Don't Know Race Asian White Black Indian/Alaskan Hawaii/Islander Don't know Marital Status Married Single Separated Divorced Widowed Common law Living together Domestic Never/Annulled Unknown Disabling condition? Yes No Don't know US Military Veteran Yes No Don't know Currently employed Yes No Don't know Currently a student Yes No Don't know Household type Adult/No child Multi Gen Single parent Two parent Total in household Adults Minors Services MOST helpful Birth Cert Employment Haircut Greeley Municipal Court Tdap Chiropractic Education Legal Counseling Child Support High Plains library Health Screening Podiatry/foot wash Government Flu Shot TB Test Mental Health Veterans Counseling/Resume Other MOST Helpful Other services to see at WPC How did you get here today? Rate benefit of today 3 - Very Helpful 2 - Helpful 1 - Not Helpful Best thing that happened Follow-up appointment? Yes No Been to WPC before Yes No If yes, what services were repeated How did you hear about WPC Newspaper Clinic Shelter Family/friends School Flyer/Poster 211 On Campus Radio/TV Community Agency Billboard/Bus Social Media Social Services Faith Org Library Hear about WPC Other Were you treated with respect? Yes No Comments/suggestions Δ
