Form 0917-0036 Patient Experience of Care Survey

IHS Pilot Patient Experience of Care Survey

Patient Experience of Care Survey

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Thank you for voluntarily participating in the Indian Health Service's patient experience of care survey.

From your perspective as a patient, we ask you to answer questions that will help our quality improvement team understand how we can improve our service to you and others who come to our clinic. 

The survey takes only a few minutes.  Using the touch screen please select the answer that best describes your experience with the care you received today. We welcome your comments and suggestions of how we can provide better care.

Your name and personal information are protected and won’t be connected with your answers.

Background: The survey was based on a survey from Southcentral Foundation, an Alaskan native-owned health care organization. Surveys will not be shared with other entities, including Southcentral.

OMB BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 10 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Indian Health Service, Office of Management Services, Division of Regulatory Affairs, 5600 Fishers Lane, Mail Stop 09E70, Rockville, MD 20857, RE: OMB Control No. 0917-0036. Please DO NOT SEND this form to this address.

If you have questions or need assistance, just ask -- our staff is ready to help you.

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* 1. An appointment was available when I needed it.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

Please comment:

* 2. When I arrived for my visit, I did not have to wait too long to be seen by my provider.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

Please comment:

* 3. The clinic staff were courteous.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

Please comment

* 4. I have trust in the clinic staff.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

Please comment:

* 5. The clinic was clean.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Please comment:

* 6. The provider listened carefully

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

Please comment:

* 7. I received the right amount of attention and time from my provider.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Please comment:

* 8. I was provided with enough information to make decisions

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

Please comment:

* 9. I was given the chance to provide input into decisions about my care.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Please comment:

* 10. My culture and traditions were respected.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Please comment:

* 11. I would recommend my provider to family and friends.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Please comment:

* 12. Overall, I am satisfied with my visit.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Please comment:

* 13. My gender (optional)

Male

Female

Other

* 14. I am a tribal member (optional)

Yes

No

Comments:

Done

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