Form 0917-0036 PT/OT (Therapy Department) - Provision of Care Survey

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Patient Experience Survey

1. I have a person who I think of as my personal physical/occupational therapist.

Strongly Disagree Disagree Neither Disagree or Agree Agree Strongly Agree

2. It is very easy for me to get into physical/occupational therapy when I need it.

Strongly Disagree Disagree Neither Disagree or Agree Agree Strongly Agree

3. Most of the time, when I visit the therapy department, it is well organized and does not waste my time.

Strongly Disagree Disagree Neither Disagree or Agree Agree Strongly Agree

4. The information given to me about my therapeutic issues is very good.

Strongly Disagree Disagree Neither Disagree or Agree Agree Strongly Agree

5. I am sure that I can manage my exercises independently and have a better understanding about injury prevention.

Strongly Disagree Disagree Neither Disagree or Agree Agree Strongly Agree

6. Overall, the care I received at the White Earth Health Center – therapy department meets my needs.

Strongly Disagree Disagree Neither Disagree or Agree Agree Strongly Agree

7. The care I received in therapy was of high quality, efficient and the staff were very professional.

Strongly Disagree Disagree Neither Disagree or Agree Agree Strongly Agree

Please feel free to share comments about your experience:

Patient Phone # (If issues need to be addressed):

Estimated Average Burden Time per Response

Public reporting burden for this collection of information is estimated to average 3 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Information Collection Clearance Officer, Indian Health Service, OMS, Mail Stop 09E70, Rockville, MD 20857, ATTN: DRA (OMB Control No. 0917–0009). Please do not send this form to this address

Revised 11/15/11