Form 0917-0036 Gallup Service Unit Patient Satisfaction Survey

Form Approved.

OMB Form No. 0917-0036

Expiration Date:

G allup Service Unit

Patient Satisfaction Survey Date:

Please complete this survey AFTER your visit to let us know how we can improve and better serve you and your family.

		Strongly Agree 5	Agree 4	Neutral 3	Disagree 2	Strongly Disagree 1
Receptionist (Appointment Clerk)
I am satisfied with the check-in process.
The receptionist was friendly and helpful.
Patient Registration
I am satisfied with the registration process.
Patient registration staff was friendly and helpful.
Clinic
I am satisfied with the cleanliness of the clinic.
I am aware of how to make a complaint.
The time I spent waiting for my appointment is acceptable.
If my waiting time was extended, it was explained to me.
Nursing Staff
The nursing staff treated me with respect and courtesy.
The nursing staff answered my questions.
I am happy with the care I received from the nursing staff.
Medical Staff
The medical staff treated me with respect and courtesy
The medical staff explained treatment procedures and plan of care in a way I understood them.
I am happy with the care I received from the medical staff.
Other
I am satisfied with the overall care and treatment of this clinic.
I would recommend this clinic to family and friends.
Comments
Can you state any good or bad experiences that occurred during your visit? Can you state at least one primary concern that the clinic could have done better? Is there anyone you want to recognize that went above and beyond your needs?

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0036.  The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.