0917-0036 Optometry Survey

FORM APPROVED

OMB Form No. xxxx

Expiration Date:xxxxx

IHS Patient Experience of Care Survey-

Optometry

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 optometrist
3	The optometry staff was courteous
4	I have trust in the optometry staff
5	The optometry clinic was clean
6	The optometrist listened carefully
7	I received enough time from my optometrist
8	I was provided with enough information to make decisions
9	I consider White Earth Service Unit to be my Medical Home
10	I was given the chance to provide input into decisions about my care
11	My culture and traditions were respected.
12	I would recommend the optometry department to family and friends
13	Overall, I am satisfied with my visit

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