Form 0917-0036 We Care Patient Satisfaction Survey for Northern Cheyenn

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

OMB 0917-0036, We Care Patient Satisfaction Survey for Northern Cheyenne.pub

We Care Survey, Northern Cheyenne

OMB: 0917-0036

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We Care

Care Provider/Location:

Date of Visit:

Would you like to be contacted about any concerns? Yes No

Name: ___________________________________

Address: _________________________________

_________________________________________

Phone: __________________________________

Northern Cheyenne Service Unit

We value your opinion. Thank you for taking a moment to let us know about your visit today.

How easy was it to access your Primary Care Team?

Your concerns/comments:

Poor

Fair

Good

Excellent

How was our customer service today?

Poor

Fair

Good

Excellent

How was your wait time?

Poor

Fair

Good

Excellent

How did your team perform today?

Poor

Fair

Good

Excellent

How were your needs met today?

Poor

Fair

Good

Excellent

How was your overall experience today?

Poor

Fair

Good

Excellent

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0036.  The time required to complete this information collection is estimated to average five minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

Form Approved

OMB Form No. 0917-0036

Expiration Date:

BELOW THIS IS FOR INTERNAL USE ONLY

Date Received by Risk Management Department _______________ Assigned Tracking Number _____________

Date Referred on for further investigation _____________________ Date Investigation Completed __________

Referred to: ______________________________________________

Date Returned to Risk Management Department ________________ Complainant Contacted on _____________

Date Closed ____________________________________________ □ Phone □ Letter □ Email

Comments: _____________________________________________________________________________________________

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______________________________________________________________________________________________________________________________________________________________________________________________________________

File Typeapplication/vnd.ms-office
AuthorTallbull, Cheyenne (IHS/BIL)
File Modified0000-00-00
File Created0000-00-00

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