Form 0920-0953 Patient Satisfaction Survey-Rutgers 12.10.13

THE WORLD TRADE CENTER MONITORING & TREATMENT PROGRAM Clinical Center at Rutgers: Robert Wood Johnson Medical School Environmental and Occupational Health Sciences Institute 170 Frelinghuysen Road, Piscataway, NJ 08854 Tel. 848-445-0123 / Fax 732-445-0127

Formed Approved

OMB No. 0920-0953

Exp. Date 12/31/2015

Patient Satisfaction Survey

In an effort to improve our services at the Environmental and Occupational Health Sciences Institute (EOHSI) World Trade Center Monitoring & Treatment Program, we would like your feedback. Please take a few minutes to complete this survey so we can better serve you in the future. Your responses will be kept secure to the extent permitted by law.

The questions are based on a scale of 1 to 5, with 1 = very dissatisfied, and 5 = very satisfied.

Date: ____________ Very Dissatisfied Very Satisfied

1. The ease of scheduling an appointment 1 2 3 4 5

2. Your health information was maintained 1 2 3 4 5

and kept secure throughout your visit

3. You were treated in a professional manner 1 2 3 4 5

4. Time was spent discussing your health and

health needs 1 2 3 4 5

5. Your overall experience at our office 1 2 3 4 5

COMMENTS:

Would you like someone to contact you to discuss this further? If so, please give us your name and phone #: ________________________________________________________

We thank you for taking the time to complete this survey and thank you for choosing our clinic.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).