VIEWS: 13 PAGES: 2 POSTED ON: 7/30/2012
Questionnaire on Customer Experience with a Health Care Service Respondent Basic Information Name of respondent: _____________________________________ Contact information: _______________________________________________________ What does the respondent consider as his/her ethnic group?: (circle one) White, African-American, Hispanic, Asian, African, Middle Eastern. Other __________________ Gender: (circle one) Male/Female Age: (circle one): 18-30 31-50 Over 50 Occupation (circle one): Student Full time worker Part-time worker Respondent’s Responses about the Medical Service Please think about a medical office or organization like a doctor, dentist, chiropractor, or a hospital you have visited recently for your own health care need or with a child/parent/other relative. Circle the type of medical service you are thinking about: A Doctor’s office A Dentist office A Hospital Other ______________ How do you rate your total experience with this service? (check only one) ______ I have an excellent experience when I go to this service ______ My experience at this service has been good _______ When I go to this service, my experience has been just ok _______ When I go to this service, my experience has not been so good _______ My experience with this place is bad Now, please check only one response for each statement below.. Focus only on the health care/medical service you mentioned above 5 4 3 2 1 Strongly Slightly No strong Slightly Strongly agree agree opinion disagree disagree Statement ("Of ("Kind of, ("I am in ("Kind of, ("No course, yes") the no") way") yes") middle") 1. At this place, the facilities (building, waiting areas, examining areas) were very attractive and comfortable 2. The employees’ appearance is neat and professional 3. My waiting time here is reasonable 4. Employees are readily available to answer my questions and concerns 5. Their medical and billing records are accurate 6. The service I get here is exactly what I was promised 7. Employees here are courteous and respectful 8. Employees here are ready address any special needs or concerns I have 9. Employees here really have patients interest at heart. 10. Employees here give me personal attention 11. They treat all patients alike without favoring some 12. Other patients I meet here are courteous and pleasant 13. Quality of medical services I receive here is excellent 14. I will continue going to this place when I have a medical need 15. I will recommend this place to my friends Thank you very much for your time.
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