17 Patient ToolKit Survey-Provider

Attachment S - Patient Toolkit Survey-Provider

Form Approved
OMB No. 0935 -XXXX
Exp. Date XX/XX/20XX

Toolkit for Engaging Patients Provider Feedback Survey

Please complete the following survey, it should take no longer than 2 minutes to complete. It will help us measure important outcomes before and after toolkit implementation.

Provider Self-Assessment of Communication Effectiveness

	Never	Sometimes	Almost Always	Always
	1	2	3	4
I listen to my patients carefully during the visit.	⃞	⃞	⃞	⃞
I allow my patients to talk without interrupting them.	⃞	⃞	⃞	⃞
I encourage my patients to express themselves/talk.	⃞	⃞	⃞	⃞
I examine my patients thoroughly.	⃞	⃞	⃞	⃞

This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and the confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 2 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-xxxx) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857, or by email to the AHRQ MEPS Project Director at [email protected].

Provider Assessment of Toolkit Effectiveness

	Never	Sometimes	Almost Always	Always
	1	2	3	4
The Be The Expert On You note sheet helps my patients to organize important information.	⃞	⃞	⃞	⃞
The Be The Expert On You note sheet helps me in the diagnostic process.	⃞	⃞	⃞	⃞
Communication with my patients has improved after using the 60 Seconds To Improve Diagnostic Safety strategy.	⃞	⃞	⃞	⃞
My patients take less than 60 seconds to share their story.	⃞	⃞	⃞	⃞

Thank you for completing this survey.