World
Trade Center Health Program
Clinical
Center of Excellence
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.
STRONGLY DO
NOT AGREE STRONGLY
DISAGREE AGREE
Example: I felt well when I woke up this morning. |
1 |
2 |
3 |
4 |
5 |
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I felt comfortable with the equipment used. |
1 |
2 |
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4 |
5 |
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I was able to see the clinician clearly. |
1 |
2 |
3 |
4 |
5 |
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I was able to hear the clinician clearly. |
1 |
2 |
3 |
4 |
5 |
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There was enough technical assistance for my meeting with the clinician. |
1 |
2 |
3 |
4 |
5 |
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My relationship with the clinician was the same during this session as it is in person. |
1 |
2 |
3 |
4 |
5 |
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The location of the telehealth clinic is convenient for me. N / A |
1 |
2 |
3 |
4 |
5 |
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My needs were met during the session. |
1 |
2 |
3 |
4 |
5 |
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I received good care during the session. |
1 |
2 |
3 |
4 |
5 |
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Overall, I am satisfied with this telehealth session. |
1 |
2 |
3 |
4 |
5 |
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I would recommend this type of session to others. |
1 |
2 |
3 |
4 |
5 |
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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
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 a clinician who could see me more frequently
Availability of a clinician who could see me more quickly
Other______________________
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Morales-Miller, Massielle |
File Modified | 0000-00-00 |
File Created | 2021-01-14 |