Form 9017-0036 Patient Survey

Form Approved

OMB No. 0917-0036

Exp. Date 01/31/2022

Crownpoint Service Unit

JCT STATE HWY 371 & ROUTE 9, CROWNPOINT, NEW MEXICO 87313

Patient Satisfaction Survey

Please complete this survey AFTER you are finished with your visit and rate our employees.

Instructions: Please circle your answers below.

Team Receiving Care from:

Hospital/Clinic: Crownpoint Pueblo Pintado Thoreau

Team: ED Inpatient Outpatient Behavioral Health Lab Pharmacy Dental Diabetes Prog. Pediatric

Women’s Health Physical Therapy Nutritionist Optometry Radiology Medical Records PRC PBC

Age Range: 1-15 16-30 31-45 46-60 61-75 75>

Indicate your answer to corresponding questions by placing an “X” in the table below.

No.	Survey Questions:	Yes	No
1	Our general hours of operation are from 8:00 a.m. - 4:30 p.m. ED 24 hours for Emergency visits only. I can generally get the care I need during these hours for care.
2	*The staff were courteous.
3	The staff treated me with respect, consideration, and dignity.
4	The staff provided me with culturally sensitive care.
5	I am informed about my responsibilities as a patient (Brochures, Poster boards, handbooks).
6	*I obtained an appointment in an appropriate timeframe.
7	When I arrived for my visit, I did not have to wait too long to be seen by my provider.
8	*It was easy to obtain my prescription refills.
9	*My medication was explained to me in a way that was easy to understand.
10	I know who my primary care team is.
11	I know who my primary care Provider is.
12	*I am satisfied with the amount of time the Provider spent with me to address my health needs?
13	*I am satisfied with how Provider understands of my health needs and concerns.
14	Did the Provider answer your health questions or concerns and explain in a way that was easy to understand?
15	Did the Provider seems to know the important information about your medical history?
16	*Staff or Provider explained what to do if my health condition changes (gets better or worse)
17	I was given an opportunity to participate in decisions about my healthcare, except when such participation is contraindicated for medical reasons.
18	Nursing staff were helpful and responded when asked for help. (Inpatient)
19	I have trust in the Crownpoint Service Unit staff.
20	The Crownpoint Service Unit patient care areas were clean.
21	Would you recommend Crownpoint Service Unit to your family and friends?
22	*How would you rate your overall health care experience today? Good Average Poor
23	Would you like to recognize someone today whom you feel provided you extraordinary customer service? (Name/Department)
24	Ideas for improvement/comments?
25	Date:

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/DRA, 5600 Fishers Lane, Rockville, MD 20857,   Attention: Information Collections Clearance Officer.