Patient Satisfaction Survey SAMPLE by keralaguest

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									                                  PATIENT SATISFACTION SURVEY

We want to be sure that the Health Clinic/Center is doing all it can to provide the very best service
possible. We want to hear from you about how we’re doing. Please think about what your experience in
the last year has been and answer the following questions. Your answers are anonymous and will help us
improve what we do.

Please answer the questions by selecting one of the options on this scale. Place your answer in the blank
line next to each question. If you cannot answer the question because it doesn’t apply to you, please
leave the line blank.

           VERY                                                                   VERY
           POOR                POOR            FAIR            GOOD               GOOD

              1                   2                  3            4                 5

ACCESS: FOR EACH QUESTION BELOW, PLEASE RATE THE EASE OF ACCESSING
SERVICES AT THE CLINIC/CENTER.

___     (1) Ease of making an appointment for medical care by phone.

___     (2) Ability to schedule an appointment soon enough to meet your needs.

___     (3) The average length of time you have to wait between making an appointment for something
        routine (regular part of your care) and the day of your visit.

___     (4) The timeliness of returning your phone calls.

___     (5) The hours the Clinic/Center is open.

___     (6) Ability to access care after hours and on weekends from the Clinic/Center.


SERVICES: FOR EACH QUESTION BELOW, PLEASE RATE HOW WELL THE SERVICE
MEETS YOUR NEEDS.

___     (7) Healthcare services

___     (8) Assistance in applying for benefits

___     (9) Assistance in arranging transportation

___     (10) Assistance in finding a place to live

___     (11) Education about HIV/AIDS

___     (12) Assistance in referring me to other places for help (like counseling, support groups, etc.)

___     (13) Helping me figure out what I need

___     (14) Listening to me when I express concerns or discuss a problem
          VERY                                                                    VERY
          POOR                POOR            FAIR             GOOD               GOOD

              1                 2                3                4                 5


OVERALL SATISFACTION: Using the scale above, please rate the Clinic/Center on the following:

___    (15) The overall appearance of the new location the Clinic/Center is now in.

___    (16) The overall cleanliness of the new location the Clinic/Center is now in.

___    (17) The convenience of the new location.

___    (18) Overall quality of the care for your physical (medical) problems and needs.

___    (19) Overall quality of the care for other needs, like housing, getting benefits (like SSI),
       counseling, etc.

___    (20) Overall satisfaction with the Clinic/Center.

___    (21) The likelihood that you would return to the Clinic/Center for care in the future.

___    (22) The likelihood that you would recommend a friend come to the Clinic/Center if in need of
       care.


23. Do you have any other comments to offer about our services?




PERSONAL INFORMATION- OPTIONAL: Please check gender and ethnicity that applies to you.
     This information will help us to understand how to better serve our patients.

                    Male                         (1) White (non-Hispanic)
                    Female                       (2) African American (non-Hispanic)
                                                  (3) Hispanic
                                                  (4) Asian/Pacific Islander
                                                  (5) American Indian
                                                  (6) Multi-racial
                                                  (7) Other (__________________________)

								
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