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Welcome to Student Health Services

Satisfaction Survey

Please take a few minuets to fill out this survey. Your feedback about satisfaction with our services is most appreciated. It informs us about quality of the services that we are providing and of areas that need improvement. Thanks and Have a Great Day!

Dr. E Curet, Director

BACKGROUND QUESTIONS
1. Patient's first visit here	Yes	No	Date:	Time of Appt.:
2. Patient's Sex	Female		Male
3. Patient's Age
4. How long did you have to wait to be seen? (Please enter answer in minutes)

A. ACCESS TO CARE	Very Poor	Poor	Fair	Good	Very Good
1. Ease of scheduling your appointments.
2. Courtesy of person who scheduled your appointment.
3. Our helpfulness on the telephone.
4. Our promptness in returning your phone calls.
5. Ease of obtaining test results.

B. DURING YOUR VISIT	Very Poor	Poor	Fair	Good	Very Good
1. Courtesy of staff in the reception area.
2. Comfort and pleasantness of the waiting area.
3. Length of wait before going to an exam room.
4. Comfort and pleasantness of the exam room.
5. Friendliness / courtesy of the nurse practitioner.
6. Concern the staff showed for your problem.
7. Waiting time in exam room before being seen by the care provider.
8. Degree to which you were informed about any delays.
9. Nurse practitioner's instructions or explanations of medical condition and treatment.
10. Your overall experience with the counseling staff (Choose one) Charla Layne Ricardo Ayala
11. Satisfaction with the services that you received from the medical assistant and/or certified nurse assistant. (Choose one) Oseas Cantu, MA Juana Castro, CNA
12. Satisfaction with the services that you received from the Health Educator. (Choose one) Cynthia Wittenburg Peggy Andres, FNP Oseas Cantu
13. Satisfaction with telemedicine intervention.
14. Our sensitivity to your needs.
15. Our concern for your privacy.
16. Safety and security you felt at this clinic.
17. Likelihood of you recommending these services to others.

COMMENTS / RECOMMENDATIONS

(describe good or bad experiences and recommendations)