Form 0917-0036 IHS Patient Experience Survey

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Patient Experience Survey

1. I have a person who I think of as my personal doctor or nurse.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

2. It is very easy for me to get medical care when I need it.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

3. Most of the time, when I visit my doctor’s office, it is well organized and does not waste my time.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

4. The information given to me about my health problems is very good.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

5. I am sure that I can manage and control most of my health problems.

1 I do not have any 2 Not very sure 3 Somewhat sure 4 Very sure

health problems

6. Overall, the care I receive at ___________________ (add your clinic name) meets my needs.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

7. I receive exactly the care I want and need exactly when and how I want and need it.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

Comments:

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 5 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.

Revised 11/15/11