DRIS Patient Perception Survey

Patient Perception Survey - Department of Radiology and Imaging Sciences
1. TELL US HOW WE ARE DOING (Reception/Check-In)
Please fill in the bubble that best describes your experience during your visit today in this department. Only the patient
who had the test done should fill out this questionnaire.

1. Did you have to wait too long in the waiting/reception area?
j
k
l
m
n

Yes, definitely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

2. Did you have to wait too long in the examination/testing room?
j
k
l
m
n

Yes, definitely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

3. If your appointment did not start on time, did someone give you a reason for the
delay?

EXAMPLE

j
k
l
m
n

Yes

j
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l
m
n

No

j
k
l
m
n

Appointment started on time

4. How would you rate the courtesy of the reception area staff?
j
k
l
m
n

Excellent

j
k
l
m
n

Very Good

j
k
l
m
n

Good

j
k
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m
n

Fair

j
k
l
m
n

Poor

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Patient Perception Survey - Department of Radiology and Imaging Sciences
2. TELL US HOW WE ARE DOING (Physician Staff)
Please fill in the bubble that best describes your experience during your visit today in this department. Only the patient
who had the test done should fill out this questionnaire.

5. Did the doctor(s) in the Department of Radiology and Imaging Sciences explain why
you needed the tests in a way that you could understand?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

j
k
l
m
n

Did not need an explanation

j
k
l
m
n

Did not talk to a doctor about the test

6. When you had important questions to ask the doctor(s) in the Department of
Radiology and Imaging Sciences, did you get answers that you could understand?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

j
k
l
m
n

Did not have questions

j
k
l
m
n

Did not talk to a doctor in this department

EXAMPLE

7. Did you have confidence in the doctor(s) treating you in the Department of Radiology
and Imaging Sciences?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

j
k
l
m
n

Did not talk to a doctor in this department

8. Did the doctor(s) in the Department of Radiology and Imaging Sciences treat you with
respect?
j
k
l
m
n

Yes, always

j
k
l
m
n

Yes, sometimes

j
k
l
m
n

Never

j
k
l
m
n

Did not talk to a doctor in this department

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Patient Perception Survey - Department of Radiology and Imaging Sciences
9. Did the doctor(s) in the Department of Radiology and Imaging Sciences talk in front of
you as if you weren't there?
j
k
l
m
n

Yes, always

j
k
l
m
n

Yes, sometimes

j
k
l
m
n

Never

j
k
l
m
n

Did not talk to a doctor in this department

EXAMPLE

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Patient Perception Survey - Department of Radiology and Imaging Sciences
3. TELL US HOW WE ARE DOING (Nursing Staff)
Please fill in the bubble that best describes your experience during your visit today in this department. Only the patient
who had the test done should fill out this questionnaire.

10. When you had important questions to ask the nurse(s) in the Department of
Radiology and Imaging Sciences, did you get answers that you could understand?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

j
k
l
m
n

Did not have questions

j
k
l
m
n

Did not talk to a nurse in this department

11. Did you have confidence in the nurse(s) treating you in the Department of Radiology
and Imaging Sciences?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

j
k
l
m
n

Did not talk to a nurse in this department

EXAMPLE

12. Did the nurse(s) in the Department of Radiology and Imaging Sciences treat you with
respect?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

j
k
l
m
n

Did not talk to a nurse in this department

13. Did the nurse(s) in the Department of Radiology and Imaging Sciences talk in front of
you as if you weren't there?
j
k
l
m
n

Yes, always

j
k
l
m
n

Yes, sometimes

j
k
l
m
n

Never

j
k
l
m
n

Did not talk to a nurse in this department

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Patient Perception Survey - Department of Radiology and Imaging Sciences
4. TELL US HOW WE ARE DOING (Technical Staff-staff who perform the
tests/proce...
Please fill in the bubble that best describes your experience during your visit today in this department. Only the patient
who had the test done should fill out this questionnaire.

14. Did the technical staff explain the test to you in a way that you could understand?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

j
k
l
m
n

Did not need explanation

15. When you had important questions to ask the technical staff, did you get answers
that you could understand?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

j
k
l
m
n

Did not have questions

EXAMPLE

16. Did you have confidence in the technical staff treating you?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

17. Did the technical staff treat you with respect?
j
k
l
m
n

Yes, always

j
k
l
m
n

Yes, sometimes

j
k
l
m
n

Never

18. Did the technical staff talk in front of you as if you weren't there?
j
k
l
m
n

Yes, always

j
k
l
m
n

Yes, sometimes

j
k
l
m
n

Never

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Patient Perception Survey - Department of Radiology and Imaging Sciences
19. How would you rate the courtesy of the technical staff performing your tests?
j
k
l
m
n

Excellent

j
k
l
m
n

Very Good

j
k
l
m
n

Good

j
k
l
m
n

Fair

j
k
l
m
n

Poor

20. Do you feel you had enough privacy during your test?
j
k
l
m
n

Yes, completely

j
k
l
m
n

Yes, somewhat

j
k
l
m
n

No

EXAMPLE

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Patient Perception Survey - Department of Radiology and Imaging Sciences
5. TELL US HOW WE ARE DOING (Patient Safety)
Please fill in the bubble that best describes your experience during your visit today in this department. Only the patient
who had the test done should fill out this questionnaire.

21. Did the staff ask you your name and birth date before they started any tests?
j
k
l
m
n

Yes, always

j
k
l
m
n

Yes, sometimes

j
k
l
m
n

Never

22. How often did you need to explain to staff something about your condition or
treatment that you thought they should already know?
j
k
l
m
n

Often

j
k
l
m
n

Sometimes

j
k
l
m
n

Never

EXAMPLE

23. Did you receive the wrong contrast material or medicine in this department?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Do not know

24. Did you receive the wrong procedure or test in this department?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Do not know

25. Did the staff tell you what danger signals to look for after the procedure?
j
k
l
m
n

Yes

j
k
l
m
n

No

26. If you could change one thing about your experience today or if you have additional
comments that you would like to share, please use the space below.
5

6

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Patient Perception Survey - Department of Radiology and Imaging Sciences
6. DEMOGRAPHICS - To be completed by department staff
27. Date
5
6

28. Time
5
6

29. Institute
j
k
l
m
n

NCI

j
k
l
m
n

NICHD

j
k
l
m
n

NINDS

j
k
l
m
n

NEI

j
k
l
m
n

NIDCD

j
k
l
m
n

NIAID

j
k
l
m
n

NHLBI

j
k
l
m
n

NIDCR

j
k
l
m
n

NCCAM

j
k
l
m
n

NHGRI

j
k
l
m
n

NIDDK

j
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l
m
n

NIAMS

j
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l
m
n

NIAAA

j
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m
n

NIMH

j
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m
n

CC

30. Please mark the types) of procedures performed today.

EXAMPLE

c
d
e
f
g

General X-Ray

c
d
e
f
g

Mammography

c
d
e
f
g

CT Scan

c
d
e
f
g

Ultrasound

c
d
e
f
g

MRI

c
d
e
f
g

Special Procedures

c
d
e
f
g

Nuclear Medicine

c
d
e
f
g

Research PET

31. This visit is a:
j
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l
m
n

Prescheduled appointment

j
k
l
m
n

Emergency appointment

j
k
l
m
n

On-call appointment

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