3 Laboratory Patient Satisfaction Survey

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

Laboratory Patient Satisfaction Survey 3-21

WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys

OMB: 0917-0036

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Form Approved

OMB No. 0917-0036

Exp. Date: XX/XX/XXXX


Shape1

PATIENT SATISFACTION SURVEY

WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER

Laboratory Department

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The Laboratory Department kindly asks you to complete this survey. Please check the boxes that best indicate your opinion and place the form in the suggestion box. Your responses will help us improve patient services.


DATE: _____________________


Laboratory Services

Strongly

Agree

Agree

Neutral

Disagree

Strongly Disagree

The laboratory staff was professional, courteous, and friendly.







The laboratory staff explained the procedures for specimen collection required for my medical test.







The laboratory staff met my expectations when collecting blood for my medical test.







The laboratory staff gave me time to ask questions and answered them clearly.






I am satisfied with the cleanliness and appearance of the laboratory.







How long was your wait time in the laboratory?

Shape4 Shape35 minutes 16-30 minutes

Shape6 Shape5 5-15 minutes > 30 minutes


What did you like best about your visit to the laboratory?





What can we do to improve laboratory services?







We appreciate your comments – Thank You!

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 less than 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  Indian Health Service, OMS/DRPC, 5600 Fishers Lane, Rockville, MD 20857,   Attention: Information Collections Clearance Officer.


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File TitleSisseton IHS Pharmacy
AuthorHolly Rice
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