Whole Health Patient Satisfaction Survey

OMB Control Number:  2900-0770

Estimated Burden:  5 minutes

Expiration Date:  09/30/2020

WHOLE HEALTH PATIENT SATISFACTION SURVEY

OMB No. 2900-0770
Estimated Burden: 5 minutes

Expiration Date: 9/30/2020

Paperwork Reduction Act of 1995 and Privacy Act Statement:

This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 5 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services, as well as customer expectations and desires. The results of this survey will lead to improvements in the quality of service delivery by helping to shape the direction and focus of services and the patient experience. Any information you enter here is anonymous and will be kept private to the extent provided by law. Participation in this survey is voluntary, and failure to respond will have no impact on benefits to which you may be entitled.

Whole Health Department Patient Satisfaction Survey

______Oscar G. Johnson VAMC, Michigan______

Please circle the clinic you visited today:

Acupuncture Chiropractor Massage Coaching

Healing Touch BFA NADA Guided Imagery

Focused Breathing Biofeedback Meditation

Progressive Muscle Relaxation Group Class

On a scale from 1-5, please respond to the following questions:

Rating Scale:

1 – Very Dissatisfied 2 – Dissatisfied 3 – Neutral 4 – Satisfied 5 – Very Satisfied

1. How well did the appointment today meet your needs? 1 2 3 4 5

2. My provider listened carefully to me. 1 2 3 4 5

3. My provider explained things to me in a way I could understand.

1 2 3 4 5

4. Suggestions: (Please use back of paper if additional space is needed.)

Comments concerning the accuracy of the survey burden estimate and suggestions for reducing this burden should be sent to Lillian Gerhart, Whole Health Manager: [email protected]