1. No category

CCFHC
Patient Satisfaction Survey
Please tell us what you think about the service you received. Your answers will be kept private. When you have finished
the survey, please place it in the comment box. Thanks for your help.
Today’s Date:______________
1. Location of CCFHC for this visit:
□Baton Rouge □Donaldsonville □Plaquemine
2. Service(s) receiving/received this visit:
□Medical
□Dental
□Patient Assistance
□Lab Only
□WIC
□Counseling/Behavioral Health
□Other:______________
3. Please tell us about yourself (Please circle your answers or fill in blank):
Are you:
Your Gender:
Your health insurance:
A new patient
Male
Medicaid
A returning patient
Female
Medicare
No Health Insurance
Other: ___________________________
Your Race/ Ethnicity: _______________
Your Doctor/Dentist/Clinician/Nurse: _________________________
Please circle how well you think we are doing:
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
Overall satisfaction with my visit
Ability to be seen
Hours Center is Open
Convenience of Center’s location
Waiting check-in time
Waiting time in exam room
Waiting for test to be performed
Waiting for test results
Waiting for discharge/check out
Staff listens to you/takes time with you
Staff explains what you want to know about treatments
Staff answers your questions in a timely manner
Treatment is given in a timely manner
Staff is friendly and helpful to you
Nursing staff is friendly and helpful to you
Provider is friendly and helpful to you
Lab staff is friendly and helpful to you
Staff answers your questions in a timely manner
Explanation of payment and charges
Wait room/reception was comfortable
The exam rooms were clean
The restrooms were clean and adequately supplied
Facility easy to find where to go
Facility comfortable and safe while waiting
Privacy of facility
Keeping my personal information private
Great
Good
Ok
Fair
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Poor
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Not
Applicable
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
OVER (→)
03/2015
CCFHC
Patient Satisfaction Survey
30. Please estimate your wait time once you checked in with staff.
0-15 min
15-30 min
30-45 min
45-60 min
more than 60 min
31. Time of day you visited the clinic
Morning
Afternoon
Evening
32. Why did you choose CCFHC?
Convenient location
No Insurance
Great Physician & Staff
Affordable
It was recommended
Hours Opened
33. What do you like about the health center? ________________________________________________________
__________________________________________________________________________________________
34. What do you not like about the health center? _____________________________________________________
__________________________________________________________________________________________
35. What times and days of the week are convenient for your appointments? _______________________________
__________________________________________________________________________________________
36. Would you return to the center for future care?
Yes
No
If no, please tell us why:_______________________________________________________________________
__________________________________________________________________________________________
37. Would you refer others to our center?
Yes
No
If no, please tell us why:_______________________________________________________________________
__________________________________________________________________________________________
38. Please share your suggestion for improvement with us:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please provide your contact information to us if you would like for someone at Capitol City Family Health Center
to follow up with you:
THANK YOU!
03/2015