5 Optometry Patient Satisfaction Survey

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

Optometry 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


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PATIENT SATISFACTION SURVEY

WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER

Optometry Department

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The Optometry 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: _____________________


Optometry Services

Strongly

Agree

Agree

Neutral

Disagree

Strongly Disagree

The optometry staff was professional, courteous, and friendly.







I was able to receive an appointment within the time I requested.







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







I was satisfied with the exam/treatment provided by the optometrist.






What did you like best about your optometry visit?







What can we do to improve optometry 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.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSisseton IHS Pharmacy
AuthorHolly Rice
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File Created2022-01-14

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