Form 0917-0036 Coordinated Care Survey

Coordinated Care Survey

1. Introduction
The Wind River Service Unit (WRSU) is committed to improving the quality of patient care by being 
accredited as a Primary Care Medical Home (PCMH). PCMH means working with the bigger health 
care community to meet your medical needs. This patient care survey is one way to improve services. 
It allows us to see the bigger picture to your health service needs. Patient care begins with you. 
Please complete the survey based upon your last or immediate visit. It takes about 5 minutes to finish. 
Thank you for helping improve patient care. 

Form Approved 
OMB Form No. 0917­0036 
Expiration Date: 5/31/2015 
1. What is your age (by years)?
j 18­25
k
l
m
n

j 26­33
k
l
m
n

j 34­41
k
l
m
n

j 42­49
k
l
m
n

j 50­57
k
l
m
n

j 58­65
k
l
m
n

j Over 66
k
l
m
n

2. What is your gender?

j Female
k
l
m
n

j Male
k
l
m
n

3. Rate your satisfaction with the change of hours to "8:00 a.m. to 5:30 p.m. (available at
noon hour), Monday­Friday, at WRSU."

j 1­Very 
k
l
m
n

j 2­Unsatisfied
k
l
m
n

j 3­Neutral
k
l
m
n

j 4­Satisfied
k
l
m
n

j 5­Very Satisfied
k
l
m
n

Unsatisfied 

4. I receive my health care services from (check all that apply):

j Fort Washakie Health Center
k
l
m
n

j Arapahoe Health Center
k
l
m
n

j Care mostly outside IHS
k
l
m
n

5. Today, I am completing this patient care survey form:

j at Fort Washakie Health Center
k
l
m
n

j online
k
l
m
n

j at Arapahoe Health Center
k
l
m
n

j by mail
k
l
m
n

j by telephone
k
l
m
n

6. What services are you receiving today?
c Behavioral Health
d
e
f
g

c Lab/X­Ray
d
e
f
g

c Clinic Health Care
d
e
f
g

c Optometry
d
e
f
g

c Community Health/Public Health Nursing
d
e
f
g

c Contract Health Services (CHS)
d
e
f
g

c Dental
d
e
f
g

c Pharmacy
d
e
f
g

c Physical Therapy
d
e
f
g

c Other (please list here):
d
e
f
g

Page 1

Coordinated Care Survey
7. Do you support both the Tribal Health Programs of the Eastern Shoshone and Northern
Arapaho having access to your patient information?
j Yes
k
l
m
n

j No
k
l
m
n

j Unsure
k
l
m
n

j Don't know
k
l
m
n

2. Coordinated Care: Your health care experiences with non­IHS clinic provider...
8. The clinic coordinates its services with the WRSU departments/programs to assist in
meeting my health care needs.
j Very Unsatisfied
k
l
m
n

j Unsatisfied
k
l
m
n

j Neutral
k
l
m
n

j Satisfied
k
l
m
n

j Very Satisfied
k
l
m
n

9. Rate your satisfaction with the care from outside services to which you were referred
c Very Unsatisfied
d
e
f
g

c Unsatisfied
d
e
f
g

c Neutral
d
e
f
g

c Satisfied
d
e
f
g

c Very Satisfied
d
e
f
g

10. Rate if services are well coordinated from the clinic to all my outside providers.
j Very Unsatisfied
k
l
m
n

j Unsatisfied
k
l
m
n

j Neutral
k
l
m
n

j Satisfied
k
l
m
n

j Very Satisfied
k
l
m
n

11. In the last 12 months, how many times have you gone to the emergency room for your
health care?
j None
k
l
m
n

j 1­3 times
k
l
m
n

j 4­6 times
k
l
m
n

j 7­9 times
k
l
m
n

j 10 or more times
k
l
m
n

Other (please explain). 

12. How satisfied are you with the care you received today?
j Very Unsatisfied
k
l
m
n

j Unsatisfied
k
l
m
n

j Neutral
k
l
m
n

j Satisfied
k
l
m
n

j Very Satisfied
k
l
m
n

13. Staff at WRSU talk to me about the "team" idea that they use with my health care.

j 1­Never
k
l
m
n

j 2­Rarely
k
l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

14. The provider and/or care team include my family as needed in patient care decisions,
treatment, and education.

j 1­Never
k
l
m
n

j 2­Rarely
k
l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

15. Staff discussed my values, beliefs, and traditions when they recommended treatments
to me.

j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n

j Often
k
l
m
n

j Always
k
l
m
n

Please list how your care team be culturally respectful? 

Page 2

Coordinated Care Survey
16. When you are ill how often do you use Native American Medicine?

j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n

j Often
k
l
m
n

j Always
k
l
m
n

17. How often do you use complementary alternative health care e.g., acupuncture,
chiropractic care, or other alternative medicine?

j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n

j Often
k
l
m
n

j Always
k
l
m
n

18. Please provide any comments that can help us improve services. Thank you.
5
6

19. Today's date
MM
Date

DD
/

YYYY
/

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. The time required to complete this information collection is estimated to average 5 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. 

Page 3