Rehabilitation Care Services Satisfaction Survey

Rehabilitation Care Services Satisfaction Survey

OMB No. 2900-0770
Estimated Burden: 5 minutes

Expiration Date: 9/30/2020

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 5 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

DATE__________ Rehab Care Services – Patient Satisfaction Survey

YOUR OPINION IS IMPORTANT TO US!

In order to improve the care we provide, we would like to know how you feel about the care you received today.

Check which clinic you were seen in today (choose one): Audiology Blind Rehabilitation Chiropractor Occupational Therapy (OT) Physical Therapy (PT) Physician Psychology Recreation Therapy Speech Language Pathology
For each statement, check the column that best describes your experience.		Strongly Agree	Agree	Neither Agree Or Disagree	Disagree	Strongly Disagree	Not Applicable
		5	4	3	2	1	N/A
1	The person who checked me in today was courteous and helpful
2	The provider I saw for my appointment today listened to my concerns.
3	The provider I saw for my appointment today provided education about my medical condition.
4	The provider I saw for my appointment today was courteous and professional.
5	I was comfortable asking questions about my care.
6	I was involved in making decisions about my care.
7	I understand the plan for my care and follow up instructions.
8	I know who to contact with questions or problems regarding my care.
9	I would recommend this clinic to others.
10	Overall, I was satisfied with this clinic visit and got all the information I needed.

Who completed this survey? Patient Caregiver

What could we have done better at today’s visit?

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If you would like to speak with someone regarding your service today, please call 206-764-2202 to speak to an RCS manager or I-CARE champion.

Please put completed survey in the box provided at the front desk….Thank you!

SEATTLE