Author: Tallbull, Cheyenne (IHS/BIL)

We Care

How easy was it to access your Primary Care Team?

Form Approved
OMB Form No. 0917-0036
Expiration Date:

Poor

Fair

Good

Excellent

Northern Cheyenne Service Unit

How was our customer service today?

Poor

Fair

Good

Excellent

We value your opinion. Thank you for taking a moment to let us know about your visit today.

How was your wait time?

Poor

Fair

Good

Excellent

How did your team perform today?

Poor

Fair

Good

Excellent

How were your needs met today?

Poor

Fair

Good

Excellent

How was your overall experience today?

Poor

Fair

Good

Excellent

Care Provider/Location:
Date of Visit:
Would you like to be contacted about any concerns? Yes No
Name: ___________________________________
Address: _________________________________
_________________________________________
Phone: __________________________________

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 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.

Your concerns/comments:

BELOW THIS IS FOR INTERNAL USE ONLY

Date Received by Risk Management Department _______________ Assigned Tracking Number _____________
Date Referred on for further investigation _____________________ Date Investigation Completed __________
Referred to: ______________________________________________
Date Returned to Risk Management Department ________________ Complainant Contacted on _____________
Date Closed ____________________________________________ □ Phone □ Letter □ Email
Comments: _____________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________

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