0917-0036 Radiology Dept Survey

FORM APPROVED

OMB Form No. xxx

Expiration Date: xxxx

xx

IHS Patient Experience of Care Survey-

Radiology Department

Thank you for voluntarily participating in the IHS Patient Experience of Care Survey. The survey takes only a few minutes. Please select the answer that best describes your experience with the care that you received today.

Your responses and participation are kept confidential and will not be connected to you.

If you have questions or need assistance, just ask---our staff is ready to help you.

What procedure did you receive today?

CIRECLE ONE: X-Ray Mammogram Ultrasound MRI CT Bone Densitometry

#	Question	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
1	An appointment was available when I needed it
2	When I arrived for my visit, I did not have to wait too long to be seen by my radiology tech
3	The department staff was courteous
4	The department was clean
5	I was provided with an explanation of my procedure
6	I was given the chance to provide input or ask questions about the procedure
7	I would recommend the radiology department to family and friends
8	Overall, I am satisfied with my visit

Comments:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your time!