Form 0920-0953 TMH QA Questionnaire

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

TMH QA Questionnaire11-25-19 mod-other dwelling

Telehealth Satisfaction at MSSM

OMB: 0920-0953

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World Trade Center Health Program

Clinical Center of Excellence




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Patient Label


Form Approved

OMB No. 0920-0953

Exp. Date 8/31/2021

Telehealth Services Patient Satisfaction Questionnaire


Date: ________________

We want to know what you thought about today’s telehealth session. Your honest answers will help us improve the system. Please circle the number that is closest to your own opinion for each of the following statements.

Shape1 STRONGLY DO NOT AGREE STRONGLY
DISAGREE AGREE

Example: I felt well when I woke up this morning.

1

2

3

4

5

I felt comfortable with the equipment used.

1

2

3

4

5

I was able to see the clinician clearly.

1

2

3

4

5

I was able to hear the clinician clearly.

1

2

3

4

5

There was enough technical assistance for my meeting with the clinician.

1

2

3

4

5

My relationship with the clinician was the same during this session as it is in person.

1

2

3

4

5

The location of the telehealth clinic is convenient for me. N / A

1

2

3

4

5

My needs were met during the session.

1

2

3

4

5

I received good care during the session.

1

2

3

4

5

Overall, I am satisfied with this telehealth session.

1

2

3

4

5

I would recommend this type of session to others.

1

2

3

4

5

I would rather use telehealth to receive this service than travel to see my clinician.

1

2

3

4

5


Did you have in-person options for today’s session? What was the location of your session today?


Yes WTC Program Clinic

No Private Home

Other

If you had other options for the session, why did you choose telehealth? (select all that apply)

  • Reduced travel time

  • Reduced travel cost

  • Shape4

    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).

    Availability of specialized clinician or treatment

  • Availability of a clinician who could see me more frequently

  • Availability of a clinician who could see me more quickly

  • Other______________________


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMorales-Miller, Massielle
File Modified0000-00-00
File Created2021-01-14

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