Form 0917-0036-12 Patient Satisfaction Survey for the White Earth Optometr

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Optometry Customer Service Questionnaire

1. During your last visit, do you feel your eye doctor listened to your concerns?

Strongly Agree Agree Neutral Disagree Strongly Disagree

2. During your last visit, did your eye doctor provide you with their full attention?

Strongly Agree Agree Neutral Disagree Strongly Disagree

3. During your last visit, do you feel your care was up-to-date with respect to modern Eye Care standards?

Strongly Agree Agree Neutral Disagree Strongly Disagree

4. During your last visit, do you feel your time with the Optometry Department Staff was well spent?

Strongly Agree Agree Neutral Disagree Strongly Disagree

5. During your last visit, did you see your doctor wash their hands (i.e. use soap and water and/or use hand sanitizer)?

Yes No I Don’t Remember

6. (Optional)

If you would like to provide additional comments about your last visit to the Optometry Department, please do so in the space provided.

_______________________________________

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 5 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.