0917-0036 Therapist Survey

FORM APPROVED

OMB Form No. xxx

Expiration Date: xxxx

xx

IHS Patient Experience of Care Survey

Occupational Therapy/Physical Therapy

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 therapist
3	The clinic staff was courteous
4	I have trust in the therapy department staff
5	The clinic was clean
6	The therapist listened carefully
7	I received enough time from my therapist
8	I was provided with enough information to make decisions
9	I was given the chance to provide input into decisions about my care
10	My culture and traditions were respected.
11	I would recommend my therapist to family and friends
12	Overall, I am satisfied with my visit

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Thank you for your time!