Form 0917-0036 Patient Experience of Care Survey

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

SURVEY PREVIEW MODE IHS Pilot Survey Final

Patient Experience of Care Survey Pilot Project

OMB: 0917-0036

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IHS Pilot Patient Experience of Care Survey

Patient Experience of Care Survey


Form Approved

OMB Form No. 0917-0036

Expiration Date:


Thank you for voluntarily participating in the Indian Health Service's patient experience of care survey.

 

From your perspective as a patient, we ask you to answer questions that will help our quality improvement team understand how we can improve our service to you and others who come to our clinic. 

 

The survey takes only a few minutes.  Using the touch screen please select the answer that best describes your experience with the care you received today. We welcome your comments and suggestions of how we can provide better care.


Your name and personal information are protected and won’t be connected with your answers.


Background: The survey was based on a survey from Southcentral Foundation, an Alaskan native-owned health care organization. Surveys will not be shared with other entities, including Southcentral.


OMB BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 10 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Indian Health Service, Office of Management Services, Division of Regulatory Affairs, 5600 Fishers Lane, Mail Stop 09E70, Rockville, MD 20857, RE: OMB Control No. 0917-0036. Please DO NOT SEND this form to this address.


If you have questions or need assistance, just ask -- our staff is ready to help you.

Top of Form

* 1. An appointment was available when I needed it.

Shape1 Strongly Agree

Shape2 Agree

Shape3 Neutral

Shape4 Disagree

Shape5 Strongly Disagree

Shape6 Not Applicable

Please comment: Shape7

* 2. When I arrived for my visit, I did not have to wait too long to be seen by my provider.

Shape8 Strongly Agree

Shape9 Agree

Shape10 Neutral

Shape11 Disagree

Shape12 Strongly Disagree

Shape13 Not Applicable

Please comment: Shape14

* 3. The clinic staff were courteous.

Shape15 Strongly Agree

Shape16 Agree

Shape17 Neutral

Shape18 Disagree

Shape19 Strongly Disagree

Shape20 Not Applicable

Please comment Shape21

* 4. I have trust in the clinic staff.

Shape22 Strongly Agree

Shape23 Agree

Shape24 Neutral

Shape25 Disagree

Shape26 Strongly Disagree

Shape27 Not Applicable

Please comment: Shape28

* 5. The clinic was clean.

Shape29 Strongly Agree

Shape30 Agree

Shape31 Neutral

Shape32 Disagree

Shape33 Strongly Disagree

Please comment: Shape34

* 6. The provider listened carefully

Shape35 Strongly Agree

Shape36 Agree

Shape37 Neutral

Shape38 Disagree

Shape39 Strongly Disagree

Shape40 Not Applicable

Please comment: Shape41

* 7. I received the right amount of attention and time from my provider.

Shape42 Strongly Agree

Shape43 Agree

Shape44 Neutral

Shape45 Disagree

Shape46 Strongly Disagree

Please comment: Shape47

* 8. I was provided with enough information to make decisions

Shape48 Strongly Agree

Shape49 Agree

Shape50 Neutral

Shape51 Disagree

Shape52 Strongly Disagree

Shape53 Not Applicable

Shape54 Please comment:

Shape55

* 9. I was given the chance to provide input into decisions about my care.

Shape56 Strongly Agree

Shape57 Agree

Shape58 Neutral

Shape59 Disagree

Shape60 Strongly Disagree

Please comment: Shape61

* 10. My culture and traditions were respected.

Shape62 Strongly Agree

Shape63 Agree

Shape64 Neutral

Shape65 Disagree

Shape66 Strongly Disagree

Please comment: Shape67

* 11. I would recommend my provider to family and friends.

Shape68 Strongly Agree

Shape69 Agree

Shape70 Neutral

Shape71 Disagree

Shape72 Strongly Disagree

Please comment: Shape73

* 12. Overall, I am satisfied with my visit.

Shape74 Strongly Agree

Shape75 Agree

Shape76 Neutral

Shape77 Disagree

Shape78 Strongly Disagree

Please comment: Shape79

* 13. My gender (optional)

Shape80 Male

Shape81 Female

Shape82 Other

* 14. I am a tribal member (optional)

Shape83 Yes

Shape84 No

Comments: Shape85

Done

Shape86 Shape87

Bottom of Form

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title[SURVEY PREVIEW MODE] IHS Pilot Patient Experience of Care Survey
AuthorWindows User
File Modified0000-00-00
File Created2022-01-14

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