Satisfaction Survey - Capitol City Family Health Center
Transcription
Satisfaction Survey - Capitol City Family Health Center
CCFHC Patient Satisfaction Survey Please tell us what you think about the service you received. Your answers will be kept private. When you have finished the survey, please place it in the comment box. Thanks for your help. Today’s Date:______________ 1. Location of CCFHC for this visit: □Baton Rouge □Donaldsonville □Plaquemine 2. Service(s) receiving/received this visit: □Medical □Dental □Patient Assistance □Lab Only □WIC □Counseling/Behavioral Health □Other:______________ 3. Please tell us about yourself (Please circle your answers or fill in blank): Are you: Your Gender: Your health insurance: A new patient Male Medicaid A returning patient Female Medicare No Health Insurance Other: ___________________________ Your Race/ Ethnicity: _______________ Your Doctor/Dentist/Clinician/Nurse: _________________________ Please circle how well you think we are doing: 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Overall satisfaction with my visit Ability to be seen Hours Center is Open Convenience of Center’s location Waiting check-in time Waiting time in exam room Waiting for test to be performed Waiting for test results Waiting for discharge/check out Staff listens to you/takes time with you Staff explains what you want to know about treatments Staff answers your questions in a timely manner Treatment is given in a timely manner Staff is friendly and helpful to you Nursing staff is friendly and helpful to you Provider is friendly and helpful to you Lab staff is friendly and helpful to you Staff answers your questions in a timely manner Explanation of payment and charges Wait room/reception was comfortable The exam rooms were clean The restrooms were clean and adequately supplied Facility easy to find where to go Facility comfortable and safe while waiting Privacy of facility Keeping my personal information private Great Good Ok Fair 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Poor 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Not Applicable 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 OVER (→) 03/2015 CCFHC Patient Satisfaction Survey 30. Please estimate your wait time once you checked in with staff. 0-15 min 15-30 min 30-45 min 45-60 min more than 60 min 31. Time of day you visited the clinic Morning Afternoon Evening 32. Why did you choose CCFHC? Convenient location No Insurance Great Physician & Staff Affordable It was recommended Hours Opened 33. What do you like about the health center? ________________________________________________________ __________________________________________________________________________________________ 34. What do you not like about the health center? _____________________________________________________ __________________________________________________________________________________________ 35. What times and days of the week are convenient for your appointments? _______________________________ __________________________________________________________________________________________ 36. Would you return to the center for future care? Yes No If no, please tell us why:_______________________________________________________________________ __________________________________________________________________________________________ 37. Would you refer others to our center? Yes No If no, please tell us why:_______________________________________________________________________ __________________________________________________________________________________________ 38. Please share your suggestion for improvement with us: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please provide your contact information to us if you would like for someone at Capitol City Family Health Center to follow up with you: THANK YOU! 03/2015
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