Form 0920-0953 WTC Environmental Health Center Customer Satisfaction Su

Form Approved

OMB No. 0920-0953

Exp. Date 8/31/2021

WTC Environmental Health Center Customer Satisfaction Survey Instrument

1. Please check the box that describes your most recent visit to the WTC EHC

 Initial Screening Visit

 Monitoring Visit

 Treatment or Diagnostic Visit

 Lab Work

 Other – Describe

2. Please use the scale below to indicate your satisfaction with the following:

	Very Satisfied	Satisfied	Neither Satisfied or Dissatisfied	Dissatisfied	Very Dissatisfied	Don’t Know/Not applicable
The ease of scheduling your visit
Convenience of clinic hours
The registration/check in process when arriving for your appointment
The courtesy and respect shown by clinic staff
The degree to which your doctor/provider listened to your medical concerns
Your overall experience with the clinic

3. We are interested in your opinions and/or recommendations so that we may improve our services. Please use the following box to make any additional comments

[TEXT BOX, open ended]

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).