Form 0917-0036 We Care Survey, Blackfeet Community Hospital.

Form Approved

OMB Form No. 0917-0036

Expiration Date:

BLACKFEET COMMUNITY HOSPITAL

"WE CARE SURVEY"

How Do You Feel About the Services		Outstanding	Above Average		Average	Below Average		Unsatisfactory
Provided to You Today in the:
DEPARTMENT
	Healthcare Provider Rating:
	1. Please Rate the Nurse
	2. Please Rate the Doctor/Provider
	3. Rate Overall Service provided
	Hospital-Wide Rating
	1. Inside Appearance
	2. Outside Appearance
	Hand Hygiene: Circle Yes, No or N/A (Not Applicable)
	Did staff clean hands with soap or alcohol rub:	Nurses		Medical Staff			Other Staff
	1. BEFORE touching patient	Yes No N/A		Yes No N/A			Yes No N/A
	2. AFTER touching patient	Yes No N/A		Yes No N/A			Yes No N/A
	3. Didn’t notice	Yes No		Yes No			Yes No

Did you notice anything during your visit that you felt was unsafe?  No  Yes if so, explain on back.

Comments (use back of form if needed)

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