5 Optometry Patient Satisfaction Survey

Form Approved

OMB No. 0917-0036

Exp. Date: XX/XX/XXXX

PATIENT SATISFACTION SURVEY

WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER

Optometry Department

The Optometry Department kindly asks you to complete this survey. Please check the boxes that best indicate your opinion and place the form in the suggestion box. Your responses will help us improve patient services.

DATE: _____________________

Optometry Services	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
The optometry staff was professional, courteous, and friendly.
I was able to receive an appointment within the time I requested.
The optometry staff gave me time to ask questions and answered them clearly.
I was satisfied with the exam/treatment provided by the optometrist.
What did you like best about your optometry visit?
What can we do to improve optometry services?

We appreciate your comments – Thank You!

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 less than 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  Indian Health Service, OMS/DRPC, 5600 Fishers Lane, Rockville, MD 20857,   Attention: Information Collections Clearance Officer.