Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire

AFTER VISIT
questionnaire
Form Approved
OMB No. 0920-0953
Exp. Date 8/31/2021

Please help us improve your experience by answering a few questions
about your recent visit at the Selikoff Centers for Occupational Health.
Your answers are completely anonymous.
1.

When scheduling your appointment, how helpful and courteous was the
staff assisting you?

o
o

a. Very Helpful
c. Not Helpful

o
o

b. Helpful
d. Does not apply

2. How satisfied are you with the ease of the check-in process at the clinic?

o
o

a. Very satisfied
c. Neutral

o
o

b. Satisfied
d. Dissatisfied

3. How well were you kept informed of any delays during your visit?

o
o

a. Informed
c. Not informed

o
o

b. Somewhat informed
d. Does not apply

4. Did the staff introduce themselves and their role to you during your visit?

o

a. Yes

o

b. No

o

c. Sometimes

5. Did the staff clearly explain benefits, such as Workers’ Compensation
benefits, Victim Compensation Fund benefits, Social Security Disability
Insurance, WTC Health Program certification, etc.

o
o

a. Yes
c. Somewhat

o
o

b. No
d. Does not apply

6. Did the doctor or nurse practitioner listen to you and address your concerns?

o

a. Yes

o

b. No

o

c. Somewhat

AFTER VISIT
questionnaire

7.

Were the next steps pertaining to your care explained to you?

o

a. Yes

o

b. No

o

c. Somewhat

8. Did you find the clinic’s facilities clean and inviting?

o

a. Yes

o

b. No

o

c. Somewhat

9. Did you find the available educational materials useful? Examples of
educational materials are: information sheets, pamphlets, the Selikoff mobile
application, etc.

o
o

a. Yes
c. Somewhat

o
o

b. No
d. Does not apply

10. Do you have any other thoughts, comments, or suggestions about how we
can improve?

Thank you for taking the time to share your input. Your feedback is greatly
appreciated as we work to improve our services for all our patients.

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).