0917-0036 Patient Registration Suvey

Patient Registration Survey
1. Introduction
The Wind River Service Unit (WRSU) is committed to improving the quality of patient care by being 
accredited as a Primary Care Medical Home (PCMH). PCMH means working with the bigger health 
care community to meet your medical needs. This patient care survey is one way to improve services. 
It allows us to see the bigger picture to your health service needs. Patient care begins with you. 
Please complete the survey based upon your last or immediate visit. It takes about 5 minutes to finish. 
Thank you for helping improve patient care. 

Form Approved 
OMB Form No. 0917­0036 
Expiration Date:  
1. What is your age (by years)?
j 18­25
k
l
m
n

j 26­33
k
l
m
n

j 34­41
k
l
m
n

j 42­49
k
l
m
n

j 50­57
k
l
m
n

j 58­65
k
l
m
n

j Over 66
k
l
m
n

2. What is your gender?

j Female
k
l
m
n

j Male
k
l
m
n

3. Rate your satisfaction with the change of hours to "8:00 a.m. to 5:30 p.m. (available at
noon hour), Monday­Friday, at WRSU."

j 1­Very 
k
l
m
n

j 2­Unsatisfied
k
l
m
n

j 3­Neutral
k
l
m
n

j 4­Satisfied
k
l
m
n

j 5­Very Satisfied
k
l
m
n

Unsatisfied 

4. I receive my health care services from (check all that apply):

j Fort Washakie Health Center
k
l
m
n

j Arapahoe Health Center
k
l
m
n

j Care mostly outside IHS
k
l
m
n

5. Today, I am completing this patient care survey form:

j at Fort Washakie Health Center
k
l
m
n

j online
k
l
m
n

j at Arapahoe Health Center
k
l
m
n

j by mail
k
l
m
n

j by telephone
k
l
m
n

6. What services are you receiving today?
c Behavioral Health
d
e
f
g

c Lab/X­Ray
d
e
f
g

c Clinic Health Care
d
e
f
g

c Optometry
d
e
f
g

c Community Health/Public Health Nursing
d
e
f
g

c Contract Health Services (CHS)
d
e
f
g

c Dental
d
e
f
g

c Pharmacy
d
e
f
g

c Physical Therapy
d
e
f
g

c Other (please list here):
d
e
f
g

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Patient Registration Survey
7. Please rate your satisfaction with the professionalism of patient scheduling staff.

j 1­Very 
k
l
m
n

j 2­Unsatisfied
k
l
m
n

j 3­Neutral
k
l
m
n

j 4­Satisfied
k
l
m
n

j 5­Very Satisfied
k
l
m
n

unsatisfied 

2.
8. Please rate your satisfaction with the amount of time it took for patient registration to
answer the phone.

j 1­Very 
k
l
m
n

j 2­Unsatisfied
k
l
m
n

j 3­Neutral
k
l
m
n

j 4­Satisfied
k
l
m
n

j 5­Very Satisfied
k
l
m
n

Unsatisfied 

9. Please rate your satisfaction with the length of time to see a provider from the
appointment time.

j 1­Very 
k
l
m
n

j 2­Unsatisfied
k
l
m
n

j 3­Neutral
k
l
m
n

j 4­Satisfied
k
l
m
n

j 5­Very Satisfied
k
l
m
n

Unsatisfied 

10. I can schedule with my primary care provider (PCP) or care team.

j 1­Never
k
l
m
n

j 2­Rarely
k
l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

11. Please rate your satisfaction with the length of time waiting for your appointment in the
reception lobby.

j 1­Very 
k
l
m
n

j 2­Unsatisfied
k
l
m
n

j 3­Neutral
k
l
m
n

j 4­Satisfied
k
l
m
n

j 5­Very Satisfied
k
l
m
n

Unsatisfied 

12. I am provided information on how to obtain medical care after­hours.

j 1­Never
k
l
m
n

j 2­Rarely
k
l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

13. The patient scheduling staff keep me up to date on my appointment when delayed.

j 1­Never
k
l
m
n

j 2­Rarely
k
l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

14. I can identify my provider or care team.
j 1­Strongly 
k
l
m
n

j 2­Disagree
k
l
m
n

Disagree 

j 3­Neutral 
k
l
m
n

j 4­Agree
k
l
m
n

j 5­Strongly Agree
k
l
m
n

(neither agree or 
disagree) 

15. My provider and/or care team explained things in a way that was easy to understand.
j Strongly 
k
l
m
n

Disagree 

j Disagree
k
l
m
n

j Neutral (neither 
k
l
m
n

j Agree
k
l
m
n

j Strongly Agree
k
l
m
n

agree or disagree) 

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Patient Registration Survey
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 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., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer. 

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