Form 0917-0036 We Care Survey, Fort Peck Service Unit, Indian Health Se

Form Approved

OMB Form No. 0917-0036

 Expiration Date: 5/30/2015

“WE CARE” Tell us how we did today!

FORT PECK SERVICE UNIT INDIAN HEALTH SERVICE

Please rate the areas you visited today. FILL in the correct square. Comments may be written on the back. Providing personal information is voluntary and will only be used to contact you in order to respond to your complaints, inquiries or comments.

Which clinic did you visit? □ Poplar □ Wolf Point

Response Definition: 1 – Poor; 2 – Below Average; 3 – Average; 4 – Good; 5 - Excellent

1 2 3 4 5 NA

RATE OUR TIMES - Access
Availability to be seen in Medical
Availability to be seen in Dental
Availability to be seen in Behavioral Health
Availability to be seen in Optometry
Availability to be seen in Audiology
Availability of Pharmacy
Availability of Public Health Nursing
Availability of Lab
Availability of Radiology
Time waiting to be seen
Hours of operation work for me
RATE OUR STAFF – Customer Service
Courtesy and helpfulness of □ Medical Records □ Reception, □ Registration □ Appointment
Courtesy and helpfulness of the Medical Team □ Eagle □ Elk □ Bear □ Turtle □ Tatanka
Courtesy and helpfulness of the Dental Staff
Courtesy and helpfulness of the Behavioral Health
Courtesy and helpfulness of the Optometry Staff
Courtesy and helpfulness of the Audiology Staff
Courtesy and helpfulness of □ Lab □ Radiology □ Pharmacy staff
Courtesy and helpfulness of □Public Health Staff □ Case Management
Courtesy and helpfulness of □ Business Office □ Benefits Coordinator □ PRC
Courtesy and helpfulness of □ Administration
Staff listened to me
My provider clearly explained about my health and treatment options
I was included in decisions about my care
I was referred to other services and was assisted with making an appointment
Staff were helpful in arranging my next appointment
Staff helped me with my concerns and answered my questions
RATE OUR FACILITY - Environment
Cleanliness and appearance
OVERALL SATISFACTION
I received quality care and was treated with dignity/ respect

“WE CARE” Tell us how we did today!

FORT PECK SERVICE UNIT INDIAN HEALTH SERVICE

What Medical Team are you on? ________________________________________

How did your Team perform today? ________________________________________

Date of Service _______________________________________

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

Comments:

Name: _______________________________________________________________________________

Address: _____________________________________________________________________________

Phone: ______________________________________________________________________________

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: _____________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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 three 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.