HOME
Department: ___________      Site: _____________

 
1. How did you hear about Ocean Health Initiatives?
Reputation of the Health Center staff.
The many health care services provided.
I've been here before and like the service.
Internet    Most convenient Health Center.
Other
Recommended by:
Family Member Employee Friend

AGREE
DISAGREE
2. My waiting time from arrival to registration was acceptable.
How long did you wait?
less than 30 minutes 1 hr 2 hrs greater than 2 hrs
Comments:
 
3. My waiting time from registration to discharge is acceptable.
1 hr 2 hrs 3 hrs greater than 3 hrs
Comments:
 
4. I am treated in a professional and courteous manner by the:
Security Officers 
Registration Clerks 
Medical Assistants 
Providers 
Nurses 
Cashiers 
Comments:
 
5. I am satisfied with the amount of time the health care providers spent with me.
Providers 
Nurses 
Comments:
 
6. I received a clear explanation concerning:
my health problem 
treatment(s) and treatment options given me 

No Pain        management of my pain 
medications prescribed 
Comments:
AGREE
DISAGREE
7. I am informed of any test results in a timely manner.
Comments:
 
8. My health information is kept private and secure.
Comments:
 
9. The Health Center and staff are meeting my needs and expectations.
Comments:
 
10. I feel safe and secure in the Health Center.
Comments:
 
11. The Health Center is clean and sanitary.
Comments:
 
12. I am satisfied with the hours the Health Center is open.
Comments:
 
13. I will recommend the Health Center to my family and friends.
Comments:
 
14. Please list what you like about us.
15. Please list those areas you think need improvement.
 
For PI Program Use Only

Demographics

  • Pt Age _______ male female
  • Today's date ____/____/___ M T W Thr F S
  • Time in:________ Time out:________