0917-0036 Public Health Nursing - for Patient Care Giver - Survey

Form Approved

OMB Form No. 0917-0036

Expiration Date:

P ublic Health Nursing

Customer Service Survey

Care- Giver

Patient’s Community/Residence:

 Black Mesa/Kitsillie  Low Mountain  Cottnwood/Blk Mtn  Valley Store  Round Rock

 Blue Gap/Tachee  Pinon  Canyon de Chelly  Many Farms  Lukachukai/U. Grswd

 Burntcorn  Smoke Signal  Spider Rock  Salina Springs  Tsaile/Black Rock

 Forest Lake  Whippoorwill  Del Muerto  Rough Rock  Wheatfields

 Hard Rock  Chinle  Nazlini  Rock Point  Other ____________

Patient’s Gender: __ Male __ Female

Patient’s Age: __ 5 years and younger __ 18 – 34 years __ 65 years and older __ 6 – 17 years __ 35 – 64 years

For each statement below circle the number based on this scale:

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

1. I would recommend Public Health Nursing (PHN) services to my family and friends 1 2 3 4 5

2. I am sure I can take care of my patient’s health 1 2 3 4 5

3. I feel comfortable discussing my patient’s care issues with PHN staff 1 2 3 4 5

4. The PHN staff helped me make a plan to improve my patient’s health 1 2 3 4 5

5. I am able to get the care I need for my patient when I need it 1 2 3 4 5

6. The PHN staff treated me and my patient with courtesy and respect at all times today 1 2 3 4 5

7. The health information given to me by the PHN staff was explained clearly 1 2 3 4 5

8. The PHN staff greeted me at the beginning of their visit 1 2 3 4 5

What did we do well today? _________________________________________________________________

How can we do better? _____________________________________________________________________

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PHN STAFF USE ONLY

• Group Visits  Family Spirit  Home Visit  Flu Clinic  Other _________________

PHN Staff Name: ­­­­­­­­­­­­­­_________________________________ Date of Visit: _________________________ Revised 04.20.15

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