Form 0917-0036 Dental Survey

FORM APPROVED

OMB Form No. 0917-0036

Expiration Date: 1/31/2022

IHS Patient Experience of Care Survey-

Dental Clinic

Thank you for voluntarily participating in the IHS Patient Experience of Care Survey. The survey takes only a few minutes. Please select the answer that best describes your experience with the care that you received today.

Your responses and participation are kept confidential and will not be connected to you.

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

Provider:

#	Question	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
1	An appointment was available when I needed it
2	When I arrived for my visit, I did not have to wait too long to be seen by my dentist
3	The dental clinic staff was courteous
4	I have trust in the dental staff
5	The dental clinic was clean
6	The dentist listened carefully
7	I received enough time from my dentist
8	I was provided with enough information to make decisions
9	I consider White Earth Service Unit to be my Dental Home
10	I have a dentist at White Earth Service Unit who I think of as my personal dentist.
11	I was given the chance to provide input into decisions about my care
12	My culture and traditions were respected.
13	I would recommend my dentist to family and friends
14	Overall, I am satisfied with my visit

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