Form 0920-0953 Telehealth Services Satisfaction Questionnaire

World Trade Center Health Program

Clinical Center of Excellence

Patient Label

Form Approved

OMB No. 0920-0953

Exp. Date 8/31/2021

Telehealth Services Patient Satisfaction Questionnaire

1.     How would you rate the ease of scheduling your telehealth appointment?

2.     Rate the explanation of your treatment by your provider during the telehealth visit.

3.     Rate the ease of communication with your care team during your telehealth visit.

4.     Rate how well the telehealth visit met your health care needs.

5.     How would you rate the telehealth visit versus the in person visit?

6.     Rate the technical quality of your telehealth visit.

7.     Rate your overall satisfaction in talking with your care team through telehealth. 

8. How likely are you to recommend our practice to a friend or loved one?

9.    Comments

Public reporting burden of this collection of information is estimated to average 1 minutes per response, including the 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 - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).