Form 0917-0036 IHS Website Customer Satisfaction Survey – EHR Survey Mo

Indian Health Service (IHS) Website Customer Service Satisfaction Survey
REQUIRED OMB INFORMATION: 
Indian Health Service (IHS) Website Customer Service Satisfaction Survey – EHR Survey Monkey – VIRTUAL 

Form Approved 
OMB Form No. 0917­0036
Expiration Date: 
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 0917­0036. The time required to complete this information 
collection is estimated to average 10 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 

OIT needs your help in evaluating the RPMS­EHR training approach. Your input will be used to help us improve our 
materials and presentation approach as we deploy the application throughout IHS.  
Questions with a * are required. 

*1. Please provide personal information:
First Name
Last Name
Credentails (RN, NP, CNM, 
LPN ­ only)
Business Address
Email
Facility
Location of Training
Date of Training
Virtual or Classroom?
Did you travel for this 
course?
Is your facility considered a 
Federal site?

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Indian Health Service (IHS) Website Customer Service Satisfaction Survey

*2. Select the term(s) that best describes your role:
c Physician
d
e
f
g

c Pharmacist
d
e
f
g
c Nurse
d
e
f
g

c Physician Assistant
d
e
f
g

c Site Manager/IT Representative
d
e
f
g

c Clinical Applications Coordinator
d
e
f
g
c Medical Records
d
e
f
g
c EHR Super User
d
e
f
g

c EHR Implementation Team
d
e
f
g
c Area Support Staff
d
e
f
g

c Other (please describe)
d
e
f
g

*3. How did you hear about this RPMS­EHR course? Select as many information sources

as apply, and/or add others:
c Web site
d
e
f
g

c Other (please describe)
d
e
f
g

*4. What did you expect from the Training?
5
6  

*5. Overall, did you feel that your objectives were met?

j Yes
k
l
m
n
j No
k
l
m
n

6. If no, describe how they could have been met better:
5
6  

*7. Were the right people from your organization at the Training?

j Yes
k
l
m
n
j No
k
l
m
n

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Indian Health Service (IHS) Website Customer Service Satisfaction Survey
8. If no, who should have attended?
5
6  

Please check a box to rate each of the statements listed below: 

*9. Please describe the quality of the presentation materials and methods used in this

training.

Materials were clearly 

Poor

Fair

Good

Very Good

Excellent

N/A

j
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l
m
n

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n

written and easy to 
understand
Training was paced 
appropriately
Sufficient time for 
comments and audience 
interaction was provided

10. Comments:
5
6  

Please check a box to rate each of the statements listed below: 

*11. Please describe the quality of the facilities used in this training.
The presentation 

Poor

Fair

Good

Very Good

Excellent

N/A

j
k
l
m
n

j
k
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n

j
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equipment/computers 
functioned properly
The room was a 
comfortable learning 
environment

12. Comments:
5
6  

*13. What part of the Training did you find most useful?
5
6  

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Indian Health Service (IHS) Website Customer Service Satisfaction Survey

*14. What part of the Training did you find least useful?
5
6  

*15. Looking back, how would you rate your

knowledge of the subject before the training?
j Poor
k
l
m
n

j Fair
k
l
m
n

j Good
k
l
m
n

j Very 
k
l
m
n

j Excellent
k
l
m
n

Good 

*16. Now that you have attended the training, how

do you rate your knowledge of the subject?
j Poor
k
l
m
n

j Fair
k
l
m
n

j Good
k
l
m
n

j Very 
k
l
m
n

j Excellent
k
l
m
n

Good 

*17. List three things you learned that you will use when you go back to your site:
5
6  

*18. Please rate the instructor:
Demonstrated knowledge of 

Poor

Fair

Good

Very Good

Excellent

N/A

j
k
l
m
n

j
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n

j
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n

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n

the subject material
Presented information 
clearly

19. Comments:
5
6  

Thank You for completing this survey.  
For a certificate of completion, please click here. 
If you have difficulty please contact Mollie Ayala at [email protected]  

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