Form 0920-0953 Telehealth Satisfaction Survey

Form Approved

OMB No. 0920-0953

Exp. Date 8/31/2021

Patient Satisfaction Quality Assurance

Date:______________

We want to know what you thought about today’s telehealth session. Your honest answers will help us improve the system. Please circle the number that is closest to your own opinion for each of the following statements.

STRONGLY DO NOT AGREE STRONGLY
DISAGREE AGREE

Example: I felt well when I woke up this morning.	1		2		3		4		5
I felt comfortable with the equipment used.	1	2		3		4		5
I was able to see the clinician clearly.	1	2		3		4		5
I was able to hear the clinician clearly.	1	2		3		4		5
There was enough technical assistance for my meeting with the clinician.	1	2		3		4		5
My relationship with the clinician was the same during this session as it is in person.	1	2		3		4		5
The location of the telehealth clinic is convenient for me.	1	2		3		4		5
My needs were met during the session.	1	2		3		4		5
I received good care during the session.	1	2		3		4		5
Overall, I am satisfied with this telehealth session.	1	2		3		4		5
I would recommend this type of session to others.	1	2		3		4		5
I would rather use telehealth to receive this service than travel to see my provider.	1	2		3		4		5

If you would like to be contacted, please provide you name and phone number.

Name:________________________________________________

Public reporting burden of this collection of information is estimated to average 5 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).