Form 0917-0036 Special Care Unit (SCU) Patient Experience Survey

Form Approved
OMB Form No. 0917-0036
Expiration Date:

Special Care Unit (SCU) Patient Experience Survey
Male: _____

Female: _____

Age: ______

Please rate the following statements using numbers
1-5 based on this scale. Circle your answers.

Date of Discharge: ______________________

1
Strongly
Disagree
1

2
Disagree

3
Unsure

4
Agree

2

3

4

5
Strongly
Agree
5

1.

I would recommend this hospital to my family and friends.

2.

Usually, my health is good.

1

2

3

4

5

3.

I am sure I can take care of my health. (T’áá hwó’ají t’éego)

1

2

3

4

5

4.

1

2

3

4

5

5.

Overall, I was pleased with how my pain was treated.
Check box if no pain
I felt safe during my stay at Chinle Hospital.

1

2

3

4

5

6.

The staff was polite and treated me and my family with respect.

1

2

3

4

5

7.

The SCU was clean and well maintained.

1

2

3

4

5

8.

The nurses explained my illness, medications, treatments, and plan of care.

1

2

3

4

5

9.

The staff was prompt in responding to alarms and requests for assistance

1

2

3

4

5

10. I was pleased with the care I received from the nursing staff.

1

2

3

4

5

11. I was pleased with the care I received from the doctors.

1

2

3

4

5

12. The nurse/therapist asked me my name before giving any medications.

1

2

3

4

5

13. The nurse/therapist checked my wristband before giving any medications.

1

2

3

4

5

14. The nurse and/or lab tech asked me my name before drawing blood.

1

2

3

4

5

15. The nurse and/or lab tech check my wristband before drawing blood.

1

2

3

4

5

16. Using a number from 0-10, where 0 is the worst possible and 10 is the best possible, what number would you choose to rate all your health care
during your hospital stay? (circle one)
0
1
2
3
4
5
6
7
8
9
10

What did we do well? ___________________________________________________________________________________________________
______________________________________________________________________________________________________________________

What can we do better? _________________________________________________________________________________________________
______________________________________________________________________________________________________________________

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 6 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.