Form 0920-0953 Rutgers Patient Satisfaction Survey 2019

The World Trade Center Responder Health Program
170 Frelinghuysen Road
Piscataway, NJ 08854
848-445-0123
Patient Satisfaction Survey

In an effort to improve our services at the Environmental and Occupational Health Sciences Institute
(EOHSI) World Trade Center Health Program, we would like your feedback. Please take a few minutes to
complete this survey so we can better serve you in the future. Your responses will be kept secure to the
extent permitted by law.
The questions are based on a scale of 1 to 5.

1 = Very Dissatisfied
Date: ____________

The World Trade Center Responder Health Program
170 Frelinghuysen Road
Piscataway, NJ 08854
848-445-0123 Patient Satisfaction Survey

Form Approved
OMB No. 0920-0953
Exp. Date 8/31/2020

Patient Satisfaction Survey
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The questions are based on a scale of 1 to 5.
The questions are based on a scale of 1 to 5.

1 = Very Dissatisfied
1 = Very Dissatisfied

5 = Very Satisfied☺

 Very Dissatisfied

☺ Very Satisfied ☺

Form Approved
OMB No. 0920-0953
Exp. Date 8/31/2020

Date: ____________
Date: ____________

5 = Very Satisfied☺
5 = Very Satisfied☺

 Very Dissatisfied
 Very Dissatisfied

☺ Very Satisfied ☺
☺ Very Satisfied ☺

1. The ease of scheduling an appointment

1

2

3

4

5

1. The ease of scheduling an appointment
1. The ease of scheduling an appointment

1
1

2
2

3
3

4
4

5
5

2. During your visit, how was your experience
with the receptionists?

1

2

3

4

5

2. During your visit, how was your experience
2.
During
your visit, how was your experience
with
the receptionists?
with the receptionists?

1
1

2
2

3
3

4
4

5
5

3. During your visit, how was your experience
with the nursing staff?

1

2

3

4

5

2
2

3
3

4
4

5
5

4. During your visit, how was your experience
with the doctor?

1

2

3

4

5

2
2

3
3

4
4

5
5

5. During your visit, how was your experience
with the mental health clinician?

1

2

3

4

5

2
2

3
3

4
4

5
5

(Turn Over)

3. During your visit, how was your experience 1
3.
During
your visit,
how was your experience 1
with
the nursing
staff?
with the nursing staff?
4. During your visit, how was your experience 1
4.with
During
your visit, how was your experience 1
the doctor?
with the doctor?
5. During your visit, how was your experience 1
5.With
During
your visit,
howclinician?
was your experience 1
the mental
health
with the mental health clinician?
(Turn Over)
(Turn Over)

The World Trade Center Responder Health Program
170 Frelinghuysen Road
Piscataway, NJ 08854
848-445-0123

The World Trade Center Responder Health Program
170 Frelinghuysen Road
Form Approved
Piscataway, NJ 08854
OMB No. 0920-0953
848-445-0123
Exp. Date 8/31/2020

Form Approved
OMB No. 0920-0953
Exp. Date 8/31/2020

Patient Satisfaction Survey

Patient Satisfaction Survey

In an effort to improve our services at the Environmental and Occupational Health Sciences Institute (EOHSI)
World Trade Center Health Program, we would like your feedback. Please take a few minutes to complete
this survey so we can better serve you in the future. Your responses will be kept secure to the extent permitted
by law.
The questions are based on a scale of 1 to 5.

In an effort to improve our services at the Environmental and Occupational Health Sciences Institute
(EOHSI) World Trade Center Health Program, we would like your feedback. Please take a few minutes to
complete this survey so we can better serve you in the future. Your responses will be kept secure to the
extent permitted by law.
The questions are based on a scale of 1 to 5.

1 = Very Dissatisfied
Date: ____________

5 = Very Satisfied☺

 Very Dissatisfied

1 = Very Dissatisfied

☺ Very Satisfied ☺

Date: ____________

5 = Very Satisfied☺

 Very Dissatisfied

☺ Very Satisfied ☺

1. The ease of scheduling an appointment

1

2

3

4

5

1. The ease of scheduling an appointment

1

2

3

4

5

2. During your visit, how was your experience
with the receptionists?

1

2

3

4

5

2. During your visit, how was your experience
with the receptionists?

1

2

3

4

5

3. During your visit, how was your experience
with the nursing staff?

1

2

3

4

5

3. During your visit, how was your experience
with the nursing staff?

1

2

3

4

5

4. During your visit, how was your experience
with the doctor?

1

2

3

4

5

4. During your visit, how was your experience
with the doctor?

1

2

3

4

5

5. During your visit, how was your experience
with the mental health clinician?

1

2

3

4

5

5. During your visit, how was your experience
with the mental health clinician?

1

2

3

4

5

(Turn Over)

(Turn Over)

1 = Very Dissatisfied

1 = Very Dissatisfied

5 = Very Satisfied☺

5 = Very Satisfied☺

5. During your visit, how was your experience
with the social worker/benefits coordinator?

1

2

3

4

5

5. During your visit, how was your experience
with the social worker/benefits coordinator?

1

2

3

4

5

6. During your visit, how was your experience
with the discharge team?

1

2

3

4

5

6. During your visit, how was your experience
with the discharge team?

1

2

3

4

5

7. Overall, how satisfied are your experience
with WTC Health Program Rutgers Clinical
Center of Excellence?

1

2

3

4

5

7. Overall, how satisfied are your experience
with WTC Health Program Rutgers Clinical
Center of Excellence?

1

2

3

4

5

Based on your visit today, if any, what improvements can be made?

Based on your visit today, if any, what improvements can be made?

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

We thank you for taking the time to complete this survey and thank you for

We thank you for taking the time to complete this survey and thank you for

choosing our clinic!

choosing our clinic!

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).
to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333 ATTN: PRA (0920-0953).
to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).

1 = Very Dissatisfied

1 = Very Dissatisfied

5 = Very Satisfied☺

5 = Very Satisfied☺

5. During your visit, how was your experience
With the social worker/benefits coordinator?

1

2

3

4

5

5. During your visit, how was your experience
With the social worker/benefits coordinator?

1

2

3

4

5

6. During your visit, how was your experience
With the discharge team?

1

2

3

4

5

6. During your visit, how was your experience
With the discharge team?

1

2

3

4

5

7. Overall, how satisfied are your experience
With WTC Health Program Rutgers Clinical
Center of Excellence?

1

2

3

4

5

7. Overall, how satisfied are your experience
With WTC Health Program Rutgers Clinical
Center of Excellence?

1

2

3

4

5

Based on your visit today, if any, what improvements can be made?

Based on your visit today, if any, what improvements can be made?

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

We thank you for taking the time to complete this survey and thank you for

We thank you for taking the time to complete this survey and thank you for

choosing our clinic!

choosing our clinic!

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA
(0920-0953).
to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the co llection of
information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333 ATTN: PRA (0920-0953).
to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).