Form 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle

Form Approved
OMB Form No. 0917-0036
Expiration Date:

Adult Care Unit (ACU) Patient Experience Survey
Male: _____

Female: ____

Age: ______

Please rate the following statements using numbers
1-5 based on this scale. Circle your answers.

Date of Discharge: ___________________

1
Strongly
Disagree
1

2
Disagree

3
Unsure

4
Agree

2

3

4

5
Strongly
Agree
5

1

2

3

4

5

1.

I would recommend this hospital to my family and friends.

2.

Usually, my health is good.

3.

I am sure I can take care of my health. (T’áá hwó’ají t’éego)

1

2

3

4

5

4.

Overall, I was pleased with how my pain was treated.
Check box if no pain
I felt safe during my stay at Chinle Hospital.

1

2

3

4

5

1

2

3

4

5

The staff was polite and treated me and my family with
respect.
My room was regularly kept clean and organized.

1

2

3

4

5

1

2

3

4

5

5.
6.
7.
8.

The nurses explained medications, my illness, treatment and
plan of care.
The staff answered my call light within 1-2 minutes.

1

2

3

4

5

1

2

3

4

5

10. I was pleased with the care I received from the nursing staff.

1

2

3

4

5

11. I was pleased with the care I received from the doctors.

1

2

3

4

5

12. The nurse asked me my name before giving any medications.

1

2

3

4

5

13. The nurse checked my wristband before giving any
medications.
14. The nurse and/or lab tech asked me my name before drawing
blood.
15. The nurse and/or lab tech check my wristband before drawing
blood.
16. I felt ready for discharge from the hospital.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

17. I was pleased with the speed of discharge process from the
hospital.
18. I was given instructions how to care for myself at home.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

9.

19. After talking to the pharmacist, I clearly understood the
purpose of taking each of my medication.
20. I can repeat what the pharmacist told me about my
medications.
21. Using a number from 0-10, where 0 is the worst possible and
10 is the best possible, what number would you choose to
rate all your health care during your hospital stay?

0

1

2

3

4

5

6

7

8

9

10

What did we do well? ________________________________________________________________________________
__________________________________________________________________________________________________
What can we do better? ______________________________________________________________________________
__________________________________________________________________________________________________

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 6 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.