Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey

Catawba Service Unit Telebehavioral Health

Patient Satisfaction Survey

Form Approved

OMB Form: 0917-0036

Expiration Date: (insert after approval)

Date of Service __________

Have you ever been involved in a telemedicine consultation before? Yes ___ No ___

How would you rate the telemedicine consultation on the factors listed below:

Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied

1 2 3 4 5

1. Does the ability to provide telemedicine consultation improve your confidence in your

primary care physician?

1. 2 3 4 5

2. Explanation of what is being done for your medical condition

1 2 3 4 5

1. Convenience of having issue taken care of same day and not waiting on referral

1 2 3 4 5

2. Ease of not having to travel for another appointment

1 2 3 4 5

3. Ability to understand the telemedicine process

1 2 3 4 5

4. Overall telemedicine consult experience

1 2 3 4 5

7. Which would you prefer (circle one): Telemedicine consultation or Physician on site?

8. Would you be willing to participate in another telemedicine consultation?

Yes ____ No ____

9. In your opinion, how important was it that you received a telemedicine consultation?

Not important Very important

1 2 3 4 5

Do you have any suggestions for improving the consultations?

Please write any additional comments below:

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.

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