Questionnaire on How Customers View Quality of a Service by VtByx1F

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									                                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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