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H H S Department of Health and Human Services
Health Resources and Services Administration
Primary Care: The Health Center Program

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Survey Form

This survey form may be downloaded, modified, printed and distributed to patients. The most efficient way to administer the survey is by using scannable forms available through the Clinical Networks, which also will scan completed forms, compile and analyze results, and develop a complete report for the health center that includes a comparison with average health center benchmarks. A nominal fee may be charged for this service.

For More Information

To learn more about the Health Center Patient Satisfaction Survey, please call 301-594-0818 and specify any special interests or needs you might have. Please provide a contact name and daytime phone number.

[Your Clinic Name Here]
Patient Satisfaction Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.

Your Age: _______

Your Sex: ___Male ___Female

Your Race/Ethnicity:
___ Asian
___ Pacific Islander
___ Black/African American
___ American Indian/Alaska Native
___ White (Not Hispanic or Latino)
___ Hispanic or Latino (All Races)
___ Unknown

Please circle how well you think we are doing in the following areas:
GREAT: 5
GOOD: 4
OK: 3
FAIR: 2
POOR: 1

Ease of getting care:
Ability to get in to be seen: 5 4 3 2 1
Hours Center is open: 5 4 3 2 1
Convenience of Center's location: 5 4 3 2 1
Prompt return on calls: 5 4 3 2 1

Waiting:
Time in waiting room: 5 4 3 2 1
Time in exam room: 5 4 3 2 1
Waiting for tests to be performed: 5 4 3 2 1
Waiting for test results: 5 4 3 2 1

Staff:
Provider: (Physician, Dentist, Physician Assistant, Nurse Practitioner)
Listens to you: 5 4 3 2 1
Takes enough time with you: 5 4 3 2 1
Explains what you want to know: 5 4 3 2 1
Gives you good advice and treatment: 5 4 3 2 1
Nurses and Medical Assistants:
Friendly and helpful to you: 5 4 3 2 1
Answers your questions: 5 4 3 2 1

All Others:
Friendly and helpful to you: 5 4 3 2 1
Answers your questions: 5 4 3 2 1
Payment :
What you pay: 5 4 3 2 1
Explanation of charges: 5 4 3 2 1
Collection of payment/money: 5 4 3 2 1
Facility:
Neat and clean building: 5 4 3 2 1
Ease of finding where to go: 5 4 3 2 1
Comfort and Safety while waiting: 5 4 3 2 1
Privacy: 5 4 3 2 1
Confidentiality:
Keeping my personal information private: 5 4 3 2 1
The likelihood of referring your friends and relatives to us: 5 4 3 2 1

What do you like best about our center?

What do you like least about our Center?

Suggestions for improvement?

Thank you for completing our Survey!