8 Radiology Patient Satisfaction Survey

Form Approved

OMB No. 0917-0036

Exp. Date: XX/XX/XXXX

PATIENT SATISFACTION SURVEY

WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER

Nutrition Services Department

The Nutrition Services Department kindly asks you to complete this survey. Please check the boxes that best indicate your opinion. Your responses will help us improve patient services.

DATE: _____________________

Nutrition Services	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
The nutrition services staff were professional, courteous, and friendly.
The nutrition services staff were knowledgeable and explained the purpose of the visit in a way I could understand.
The nutrition services staff provided me with realistic recommendations to achieve my health goals.
The nutrition services staff provided me with educational materials that were easy to read and understand.
I am satisfied with the services provided by the nutrition services staff.
What did you like best about your nutrition clinic visit?
What can we do to improve nutrition services?
We would love to hear how nutrition services has improved your health. Please share your success story.

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.