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How did we do?
The County of Marin Health and Human Services (HHS) department is committed to providing you with the best experience possible. Please take a moment to provide us with feedback on your recent interaction with our team. This information will be kept completely anonymous and will not be linked to you in any way.
Program
How well were your needs addressed?
Not at all addressed
1
2
3
Fully addressed
4
1 is Not at all addressed, 4 is Fully addressed
How respected did you feel?
Not at all respected
1
2
3
Fully respected
4
1 is Not at all respected, 4 is Fully respected
How do you rate your overall interactions with staff?
*
Poor
1
2
3
Excellent
4
1 is Poor, 4 is Excellent
Was the service provided in your preferred language?
Yes
No
How can we improve?
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Please take the time to answer these questions. We are collecting this information to understand the experiences of all populations served by Health and Human Services.
Are you of Hispanic, Latino, or Spanish decent?
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Yes
No
Prefer not to state
Please describe yourself (you may select more than one answer):
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Black or African American: A person having origins in any of the black racial groups of Africa
Asian or Asian American: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian and or Alaskan Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Native Hawaiian and or Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White or Caucasian: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Prefer not to state
Prefer to self-describe:
Self-described race:
What is your preferred language for receiving services?
Please Select
☐ American Sign Language
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☐ Cantonese
☐ Cherokee
☐ English
☐ Farsi
☐ French
☐ Haitian Creole
☐ Hebrew
☐ Hmong
☐ Kaqchikel
☐ Ki’che’
☐ Ilocano
☐ Italian
☐ Japanese
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☐ Lao
☐ Mam
☐ Mandarin
☐ Mien
☐ Miwok
☐ Navajo
☐ Polish
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☐ Portuguese
☐ Q’eqchi’
☐ Russian
☐ Samoan
☐ Spanish
☐ Tagalog
☐ Thai
☐ Turkish
☐ Vietnamese
☐ Another language not listed here (Specify): ___________________
☐ Prefer not to answer
Another language not listed (Specify):
Select what you feel best aligns with your current gender identity. (Check all that apply)
Woman (Trans* inclusive)
Man (Trans* inclusive)
Gender non-binary
Agender
Indigenous or other cultural gender identity (e.g. two-spirit)
Questioning/unsure
Transgender
Prefer not to state
Prefer to self-describe:
Self-described gender identity:
Select what you feel best describes your current sexual orientation. (Check all that apply)
Heterosexual/straight/opposite gender loving
Gay/lesbian/same gender loving
Bisexual
Asexual
Pansexual
Questioning/unsure
Prefer not to state
Prefer to self-describe:
Self-described sexual orientation:
What is your age group?
15 or younger
16-25 years old
26-59 years old
60-71 years old
72 or older
Prefer not to state
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