6a HRSA Patient Feedback Survey - English

Health Site

PATIENT FEEDBACK SURVEY

We are trying to improve the care we provide to our patients. Please take a few minutes to answer the following questions. You can skip questions you do not want to answer. This is completely voluntary and will not affect the care you receive here. Please do not write your name on this. It is completely private – no names attached. For your answers to be most helpful, please be as honest as you can. THANK YOU!

1. Today, did your healthcare provider talk to you about healthy and unhealthy relationships?

No Yes Don’t Know

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2. Today, did your healthcare provider review what they mean by the term “confidential” and the reasons they may have to break that confidentiality?

No Yes Don’t Know

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3. Today, did your healthcare provider give you either one of these palm-sized cards (pictured below)?

No Yes Don’t Know

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4. Did receiving this card or other information from your healthcare provider increase your understanding about how to help someone being hurt by a sexual partner?

No Yes Don’t Know Not applicable, I did not receive the card

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5. Have you ever experienced an unhealthy relationship or been hurt by a sexual partner?

No Yes

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Today, did you tell your healthcare provider this?

No Yes Don’t Know Not applicable, have not experienced this

   

6. How helpful or unhelpful was it to be asked about your relationship? Please circle a number below:

0	1	2	3	4	Not Applicable
Not Helpful				Very Helpful	

7. How helpful or unhelpful was it to receive information about healthy and unhealthy relationships and their impact on your health? Please circle a number below:

0	1	2	3	4	Not Applicable
Not Helpful				Very Helpful	

8. How likely are you to share information you received today on healthy and unhealthy relationships with someone you know? Please circle a number below:

   0	1	2	3	4	Not Applicable
   Not Likely				Very Likely	

9. What is your age? Are you:

10 to 24 years old 25 and over

 

Public Burden Statement: 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. The OMB control number for this project is 0915-0212. Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.