Survey Form

Frequently-Asked Questions Immunization Clinic UTA Infectious Disease Policy Insurance Laboratory Medical Staff Mental Health Peer Education Pharmacy Women's Clinic X-ray	How did you first learn about the Health Center?	Were you treated courteously at the Health Center by:
	Orientation UTA Catalog New-Student Handbook Shorthorn Student/Co-worker Other	Clerical Staff Nursing Staff Counselor	Physician Lab Technician X-ray Technician	Pharmacy Substance Abuse Peer Education
	Which of the services did you use and how satisfied were you with each? Please enter a rating in the appropriate boxes (Scale is 1 to 5; 1 is Excellent, 5 is Poor)
	SERVICES/RATINGS Please comment on ratings of "5"
	General Medicine
	Women's Clinic
	Mental Health
	Pharmacy
	Laboratory
	X-ray
	Substance Abuse Prevention
	Peer Education
	Overall

	Are there any other services you would use if provided by the Health Center? Yes Please specify. No		Do you have health insurance? Yes If so, please give the name. No

	Classification: Freshman Sophomore Junior Senior Masters Doctorate Other		Age Student status Gender Ethnic background