Form 0917-0036 OMB No. 0917-0036-39, Patient Satisfaction Survey, Tohat

Form Approved

OMB Form No. 0917-0036-39

Expiration Date: 05/31/2015

Patient Satisfaction Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving our services. Your responses will be kept in confidence and only reviewed by our administrative staff.

Thank you for your time.

Your Age: __________ How far did you travel to get here today? ________________

Gender: Male Female

Type of Pharmacy Visit Today (please check one)

Clinic Visit with Medication

Pharmacy Clinic Appointment with Medication

Medication Refill

I decline to complete survey why? ­_________________________________________________________

How do you rate…? (Please circle the appropriate number)	Excellent	Very Good	Fair	Poor	Very Poor
The Pharmacy staff were nice and polite to me	5	4	3	2	1
The time spent waiting for medication or Pharmacy Clinic appointment.	5	4	3	2	1
The Pharmacy staff verified my identity (date of birth or chart number or ID card).	5	4	3	2	1
The Pharmacy staff’s explanation of my medications was good and understandable	5	4	3	2	1
The amount of time spent with the Pharmacist.	5	4	3	2	1
The provider listened to you.	5	4	3	2	1
The pharmacy staff respected my privacy during consultation or visit.	5	4	3	2	1
Overall, the care I receive in the Pharmacy at Tohatchi Health Center meets my needs.	5	4	3	2	1
I have a provider that I think of as my personal doctor at Tohatchi Health Center.	5	4	3	2	1

Do you have any suggestions or comments as to how we may better improve our services?

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for taking the time to complete this survey. Your opinion means a lot to us.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The  valid OMB control number for this information collection is 0917-0036-39.  The time required to complete this information collection is estimated to average five minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.