Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys
SURVEY PREVIEW MODE IHS Pilot Survey Final
Patient Experience of Care Survey Pilot Project
OMB: 0917-0036
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0917-0036 can be found here:
Thank
you for voluntarily participating in the Indian Health Service's
patient experience of care survey.
From
your perspective as a patient, we ask you to answer questions
that will help our quality improvement team understand how we
can improve our service to you and others who come to our clinic.
The
survey takes only a few minutes. Using the touch screen please
select the answer that best describes your experience with the care
you received today. We welcome your comments and suggestions of
how we can provide better care.
Your
name and personal information are protected and won’t be
connected with your answers.
Background:
The survey was based on a survey from Southcentral Foundation, an
Alaskan native-owned health care organization. Surveys will not
be shared with other entities, including Southcentral.
OMB
BURDEN STATEMENT
Public
reporting burden for this collection of information is estimated to
average 10 minutes per response including 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: Information Collection Clearance Officer, Indian Health
Service, Office of Management Services, Division of Regulatory
Affairs, 5600 Fishers Lane, Mail Stop 09E70, Rockville, MD 20857,
RE: OMB Control No. 0917-0036. Please DO NOT SEND this form to this
address.
If
you have questions or need assistance, just ask -- our staff is ready
to help you.
Top
of Form
*
1.An
appointment was available when I needed it.
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Not
Applicable
Please
comment:
*
2.When
I arrived for my visit, I did not have to wait too long to be seen by
my provider.
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Not
Applicable
Please
comment:
*
3.The
clinic staff were courteous.
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Not
Applicable
Please
comment
*
4.I
have trust in the clinic staff.
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Not
Applicable
Please
comment:
*
5.The
clinic was clean.
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Please
comment:
*
6.The
provider listened carefully
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Not
Applicable
Please
comment:
*
7.I
received the right amount of attention and time from my provider.
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Please
comment:
*
8.I
was provided with enough information to make decisions
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Not
Applicable
Please
comment:
*
9.I
was given the chance to provide input into decisions about my care.
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Please
comment:
*
10.My
culture and traditions were respected.
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Please
comment:
*
11.I
would recommend my provider to family and friends.