0917-0036 Public Health Nursing - for Patient Care Giver - Survey

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

0917-0036-PHN Customer Services Survey Care Giver

OMB: 0917-0036

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Form Approved

OMB Form No. 0917-0036

Expiration Date:


P ublic Health Nursing

Customer Service Survey

Care- Giver


Patient’s Community/Residence:

Black Mesa/Kitsillie Low Mountain Cottnwood/Blk Mtn Valley Store Round Rock

Blue Gap/Tachee Pinon Canyon de Chelly Many Farms Lukachukai/U. Grswd

Burntcorn Smoke Signal Spider Rock Salina Springs Tsaile/Black Rock

Forest Lake Whippoorwill Del Muerto Rough Rock Wheatfields

Hard Rock Chinle Nazlini Rock Point Other ____________

Patient’s Gender: __ Male __ Female

Patient’s Age: __ 5 years and younger __ 18 – 34 years __ 65 years and older __ 6 – 17 years __ 35 – 64 years

For each statement below circle the number based on this scale:

1 2 3 4 5




Strongly Disagree Neutral Agree Strongly

Disagree Agree

  1. I would recommend Public Health Nursing (PHN) services to my family and friends 1 2 3 4 5

  2. I am sure I can take care of my patient’s health 1 2 3 4 5

  3. I feel comfortable discussing my patient’s care issues with PHN staff 1 2 3 4 5

  4. The PHN staff helped me make a plan to improve my patient’s health 1 2 3 4 5

  5. I am able to get the care I need for my patient when I need it 1 2 3 4 5

  6. The PHN staff treated me and my patient with courtesy and respect at all times today 1 2 3 4 5

  7. The health information given to me by the PHN staff was explained clearly 1 2 3 4 5

  8. The PHN staff greeted me at the beginning of their visit 1 2 3 4 5


What did we do well today? _________________________________________________________________

How can we do better? _____________________________________________________________________

**************************************************************************************************

PHN STAFF USE ONLY

  • Group Visits Family Spirit Home Visit Flu Clinic Other _________________


PHN Staff Name: ­­­­­­­­­­­­­­_________________________________ Date of Visit: _________________________ Revised 04.20.15

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 3 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.



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