Form 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Ce

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Patient Satisfaction Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving our services. Your responses will be kept in confidence and only reviewed by our administrative staff.

Thank you for your time.

Your Age: __________ How far did you travel to get here today? ________________

Gender: Male Female

I decline to complete survey why? ­_________________________________________________________

How do you rate…? (Please circle the appropriate number)	Excellent	Very Good	Fair	Poor	Very Poor
The time it took us to answer your call or schedule your appointment	5	4	3	2	1
The manner of the person who scheduled your appointment	5	4	3	2	1
Your wait time to be screened after you checked in	5	4	3	2	1
Your screeners retrieval of vital signs	5	4	3	2	1
Your nurse’s review of medications and Assessment	5	4	3	2	1
Your wait time in the room before the provider arrived	5	4	3	2	1
The amount of time spent with your provider.	5	4	3	2	1
The provider listening to you.	5	4	3	2	1
The provider’s explanation of procedure, diagnosis, or treatment?	5	4	3	2	1
Overall quality of care and service provided by IHS.	5	4	3	2	1
I have a person who I think of as my personal doctor or nurse.	Strongly Agree5	Agree4	Neutral3	Disagree2	Strongly Disagree1
I am able to get the care I need and want - when I need and want it at the clinic.	Strongly Agree5	Agree4	Neutral3	Disagree2	Strongly Disagree1
I am sure that I can manage and control most of my health problems.	Very sure or No health problems5	Somewhat sure4	Neutral3	Not very sure2	Not at all1

Do you have any suggestions or comments as to how we may better improve our services?

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for taking the time to complete this survey. Your opinion means a lot to us.

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 five 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.