Form 0917-0036 Whiteriver Service Unit (WRSU) Birthing Center Patient S

FORM APPROVED

OMB No. 0917-xxxx

Exp. Date:

WRSU Birthing Center

Patient Satisfaction Survey

To be completed prior by women who delivered at WRSU prior to discharge from the Birthing Center or at initial postpartum / weight & color check.

Please help us make giving birth at Whiteriver better and better! Your answers are anonymous - do not include your name or personal information. Thank you!

1. Did the nurses provide education and support during your delivery and stay?

 No, not at all  Only a little  Yes, somewhat Yes, definitely

2. Did the doctors provide education and support during your delivery and stay?

 No, not at all  Only a little  Yes, somewhat Yes, definitely

3. How would you rate your overall delivery experience at WRSU?

 Very poor  Poor  Average  Good  Excellent

4. Would you plan to deliver future children at WRSU?

 Yes  No  unsure  does not apply

5. Would you recommend delivery at WRSU to family or friends who are pregnant?

 Yes  No  unsure  does not apply

6. What did you like about delivering at Whiteriver?

7. What could we do to improve your delivery experience?

8. Please provide any additional comments:

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 collection is 0990-XXXX. 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 Collection Clearance Officer.