Form 0917-0036 Dental Survey

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

Dental Survey Update 04232019

Patient Experience Surveys - White Earth Service Unit

OMB: 0917-0036

Document [docx]
Download: docx | pdf




Shape1

FORM APPROVED

OMB Form No. 0917-0036

Expiration Date: 1/31/2022


IHS Patient Experience of Care Survey-

Dental Clinic

Thank you for voluntarily participating in the IHS Patient Experience of Care Survey. The survey takes only a few minutes. Please select the answer that best describes your experience with the care that you received today.

Your responses and participation are kept confidential and will not be connected to you.

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



Provider:

#

Question

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

1

An appointment was available when I needed it






2

When I arrived for my visit, I did not have to wait too long to be seen by my dentist






3

The dental clinic staff was courteous






4

I have trust in the dental staff






5

The dental clinic was clean






6

The dentist listened carefully






7

I received enough time from my dentist






8

I was provided with enough information to make decisions






9

I consider White Earth Service Unit to be my Dental Home






10

I have a dentist at White Earth Service Unit who I think of as my personal dentist.






11

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






12

My culture and traditions were respected.






13

I would recommend my dentist to family and friends






14

Overall, I am satisfied with my visit







Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWasson, Lynette (IHS/BEM)
File Modified0000-00-00
File Created2022-01-14

© 2024 OMB.report | Privacy Policy