Form 0917-0036 Obstetrical Care Unit (OCU) Patient Experience Suvey, Ch

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

Obstetrical Care Unit (OCU) Patient Experience Survey
Please take this short time for answering the survey questions. We want to know how you and your family felt
about your stay on OCU. Thank you.
Date of Discharge: ____________________
Patient’s Age: ________________
Patient’s Gender: _________________
EPL=86%
Please rate the following statements
using numbers 1-5 based on this
scale.

1.
2.
3.
4.
5.
6.
7.
8.

9.

10.

11.
12.

1
Strongly
Disagree
1

2
Disagree

3
Unsure

4
Agree

2

3

4

5
Strongly
Agree
5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Introduced themselves.

1

2

3

4

5

Checked our (baby and I) ID
bands, and allergy bands.
Explained my birth experience.

1

2

3

4

5

1

2

3

4

5

During my stay,

1

2

3

4

5

I felt involved in treatment
plans for myself.
I felt involved in treatment
plans for baby.
During my stay, the staff assisted
me…
With breastfeeding.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

With newborn care.

1

2

3

4

5

My cultural needs were respected.

1

2

3

4

5

I would recommend this hospital to my
family and friends.
Usually, my health is good.
I am sure I can take care of my health.
(T’áá hwó’ají t’éego)
Pain: Overall, I was pleased with how
my pain was treated.
Safety: I felt safe during my stay at
Chinle Hospital
Respect: The staff was polite and
treated my family and me with respect.
Environment: The unit was clean and
organized.
During my stay, the staff:

N/A

No Pain

The visitors’ policy was explained to
1
2
3
4
5
me.
Using a number from 0 to 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)

13.

1
2
3
4
5
6
7
8
9
10
Upon discharge, I felt comfortable going home to take care of myself and my baby.
no, why?

14.

What did we do well?

15.

What can we do better?

Did you get an Education Booklet?
16.

Yes

Yes

No, if

No

Was your last baby delivered at Chinle Hospital prior to 2012?
Yes

No

N/A

(If No or N/A, you are done with your survey)

17.

If Yes to questions #16, what have you noticed that changed on Obstetric Care Unit:

18.

Using a number from 0 to 10, where 0 is the worst possible and 10 is the best possible, what number would you
choose to rate the improvements made on OCU since your last delivery? (circle one)
1

2

3

4

5

6

7

8

9

10

19.

Do you have any complaints regarding your care or services during your visit? If so, how can we improve your
care/service?

20.

Did a family member stay with you 24/7 after you had your baby? Yes
No
experience having a family member stay with you 24/7 after you had your baby?

If yes, how was your

Your input is important to us to improve our services to our mother, families, and babies. Thank 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 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.