Form 0920-0953 Patient Satisfaction Survey

Attachment A

Patient Satisfaction Survey

Formed Approved OMB No. 0920-0953

Exp. Date 8/31/2021

Patient Satisfaction Survey

In an effort to improve our services at the Long Island World Trade Center Health Program, we would like your feedback on how your visit to our office was. We ask that you to take a few moments to complete this survey, so we can better serve you in the future. Your responses will be kept secure to the extent permitted by law.

The questions are based on a scale of 1 to 5, with 1 = very dissatisfied and 5 = very satisfied. We have added additional comment sections so you are able to explain any thoughts and/or feelings you may have. Please return this in the envelope provided.

How satisfied are		you with:	Very Dissatisfied		Satisfied		Very Satisfied	Not Applicable
1.	The ease of scheduling your monitoring visit		1	2	3	4	5	9
2.	The courtesy and respect given to you by receptionists and clerks		1	2	3	4	5	9
3.	The wait time after checking in for your appointment		1	2	3	4	5	9
4.	The professional conduct of the clinical staff		1	2	3	4	5	9
5.	The knowledge and competence of your clinician		1	2	3	4	5	9
6.	The thoroughness of your exam		1	2	3	4	5	9
7.	Your clinician’s attention to your medical concerns		1	2	3	4	5	9
8	The understandability of the medical explanations and instructions given to you by the clinician		1	2	3	4	5	9
9.	The cleanliness of the facilities		1	2	3	4	5	9
10.	The availability of convenient treatment options		1	2	3	4	5	9
11.	The ease of filling your prescription		1	2	3	4	5	9
12.	The ability of our clinic to meet your WTC health care needs overall		1	2	3	4	5	9

Public reporting burden of this collection of information is estimated to average 4 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).

Please tell us about anyone or anything that particularly impressed you or particularly annoyed you. If you rated any item above as a “1” or a “2”, please tell us why in the space below.

Additional comments:

Would you like someone to contact you to discuss this further? If so, please give us your name and phone

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We thank you for taking the time to complete this survey and look forward to serving you in the future!