Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey

Form Approved

OMB Form No. 0917-0036             

Expiration Date:

Catawba Service Unit Patient Satisfaction Survey

Please fill out the information for this visit and give to surveyor.

Who are you seeing today: Circle all that apply

Dentist Lab only Nurse Nutritionist Medical Provider Pharmacy only Other:_______________

Who was your provider today:_____________________________________________________________

Circle one number for each question:

1= Strongly Disagree 2=Disagree 3=Neither Disagree or Agree 4=Agree 5=Strongly Agree

1. I have a person who I think of as my personal doctor or nurse 1 2 3 4 5

2. It is easy for me to get medical care when I need it 1 2 3 4 5

3. Most of time when I visit office, it is well organized and does not waste my time 1 2 3 4 5

4. The information given me about my health problems is very good 1 2 3 4 5

5. I am sure that I can manage and control most of my health problems 1 2 3 4 5

6. Overall, the care I receive at the Catawba Service Unit meets my needs 1 2 3 4 5

7. I am able to get the care I need and want- when I need and want it at the clinic 1 2 3 4 5

Use these rating for questions below 1= Very Dissatisfied 2=Dissatisfied 3=Neutral 4=Satisfied 5=Very Satisfied

8. Did provider answer your questions 1 2 3 4 5

9. Did provider explain things to you 1 2 3 4 5 21.How many minutes did you

10. Was provider friendly to you 1 2 3 4 5 have to wait before a doctor

11. Did RN answer your questions 1 2 3 4 5 saw you?

12. Did RN explain things to you 1 2 3 4 5 0-10 min

13. Was RN friendly to you 1 2 3 4 5 11-20 min

14. Did other staff answer your questions 1 2 3 4 5 21-30 min

15. Did other staff explain things to you 1 2 3 4 5 30-60 min

16. Was other staff friendly to you 1 2 3 4 5 Over 60 min

17. Ease of getting medical appointment 1 2 3 4 5

18. Ease of getting dental appointment 1 2 3 4 5

19. Wait time to see provider 1 2 3 4 5

20. Overall satisfaction with CSU Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied

During you visit did any staff member go above the call of duty to make your visit better or more enjoyable? If so please let us know whom and what they did so we can encourage this._________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any recommendations or suggestions that could help us improve the care we offer for you?

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