Healthcare Provider and System Consumer Assessment Survey Form
Share general feedback about your experience with healthcare services.
How would you rate your overall experience with the healthcare services you used?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How satisfied were you with the following aspects of your experience?
*
Rows
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
Ease of accessing services
1
2
3
4
5
Courtesy and respect
6
7
8
9
10
Clarity of communication
11
12
13
14
15
Coordination between services
16
17
18
19
20
How easy was it to access the services you needed?
*
Very difficult
Difficult
Neither easy nor difficult
Easy
Very easy
Not applicable
How well did the provider or staff explain information in a way that was easy to understand?
*
Not at all well
1
2
3
4
Extremely well
5
1 is Not at all well, 5 is Extremely well
How often did you feel treated with courtesy and respect?
*
Never
Rarely
Sometimes
Usually
Always
Not applicable
How satisfied were you with the time and attention you received?
*
1
2
3
4
5
How well did the services you used seem coordinated?
*
Not at all well
1
2
3
4
Extremely well
5
1 is Not at all well, 5 is Extremely well
Overall, how confident are you in the quality of the services you received?
*
Not at all confident
1
2
3
4
Extremely confident
5
1 is Not at all confident, 5 is Extremely confident
What is one thing that worked particularly well in your experience?
What is one improvement that would make the experience better?
Submit Assessment
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