The Nationwide Provider Network Customer Satisfaction Survey

Formed Approved
OMB No. 0920-0953
Exp. Date 12/31/2015

Exp. Date 12/31/2015W TC HEALTH PROGRAM NATIONWIDE PROVIDER NETWORK

CUSTOMER SATISFACTION SURVEY – CALL CENTER/CLINIC

Member Information
Name:		Phone:
Clinic Name:		City and State:			Zip Code:
Date of Examination:	Services Received:		Work-up Appointment	Monitoring Exam

PLEASE CIRCLE THE RESPONSE THAT BEST DESCRIBES THE QUALITY OF SERVICES PROVIDED.

Call Center/Scheduling Process

1. The time it took for your call to be answered during the call center/scheduling process.

< 2 min 2-3 min 3-4 min > 4 min N/A

2. The call center/scheduling staff’s courtesy and professionalism.	Excellent	Good	Satisfactory	Poor	N/A
3. The call center/scheduling staff’s knowledge and willingness to answer your questions.	Excellent	Good	Satisfactory	Poor	N/A
4. Your overall satisfaction with the information you received.	Excellent	Good	Satisfactory	Poor	N/A
5. Your overall satisfaction with the call center/scheduling process.	Excellent	Good	Satisfactory	Poor	N/A
If you have circled ‘Poor’ for any of the above items, please provide further details:

Please let us know any suggestions you may have for LHI to make improvements:

In-Clinic Process
1. The clinic staff’s courtesy and professionalism.	Excellent	Good	Satisfactory	Poor	N/A
2. The clinic staff’s knowledge and ability to answer your questions.	Excellent	Good	Satisfactory	Poor	N/A
3. The condition of the clinic facility	Excellent	Good	Satisfactory	Poor	N/A
4. Your overall satisfaction with clinic.	Excellent	Good	Satisfactory	Poor	N/A

5. Indicate the length of time you waited prior to your exam. < 10 min 10-20 min 21-40 min > 40 min

If you have circled ‘Poor’ for any of the above items, please provide further details:

Please let us know any suggestions you may have for LHI to make improvements:

Please give us any feedback related to your past experience with the WTC Nationwide Provider Network Program:

Public reporting burden of this collection of information is estimated to average 4 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).

You may leave this survey with the clinic or mail/fax to LHI at the address/ number listed below.

Thank you for completing this survey!

Logistics Health Incorporated / 328 Front Street South / La Crosse, WI 54601 / Tel: 877.498.2911 / Fax: 608.793.2964