WPC Guest Survey NameZip/TownDon'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 householdAdultsMinorsServices MOST helpful Birth Cert Child Support Flu Shot Employment Education High Plains library TB Test Haircut Legal Counseling Health Screening Mental Health Podiatry/foot wash Veterans Tdap Government Counseling/Resume Other MOST HelpfulOther services to see at WPCHow did you get here today?Rate benefit of today 3 – Very Helpful 2 – Helpful 1 – Not Helpful Best thing that happenedFollow-up appointment? Yes No Been to WPC before Yes No If yes, what services were repeatedHow 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 OtherWere you treated with respect? Yes No Comments/suggestions Δ
