Please complete this brief, confidential survey.  Your responses will help us validate or improve our services.

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* 1. When were you seen in our Occupational Medicine clinic?

Date:

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* 2. Which location did you visit?

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* 3. What service did you receive? 
Please check all that apply.

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* 4. How many minutes did you wait in the lobby?

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* 5. If you saw a provider, how many minutes did you wait in the exam room before he/she arrived?

Please rate your experience in each of the following areas. 
If anything does not apply, select N/A for "Not Applicable".

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* 6. Experience with clinic staff:

  Very Good Good Neutral Bad Very Bad N/A
Friendliness and helpfulness of front desk
Professionalism and skill of nurses
Response to your questions or concerns
Respect of your privacy
Overall attentiveness and attitude

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* 7. Experience with the provider (if applicable):

  Very Good Good Neutral Bad Very Bad N/A
Responsiveness to your problem or pain
Explanation of procedures, diagnosis and treatment
Explanation of medications or equipment
Explanation of work restrictions, if any

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* 8. Overall, how well did our staff work together to provide your service?

About You (optional):

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* 9. Gender:

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* 10. Age:

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* 11. Your Name:

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* 12. Your Employer:

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* 13. Additional comments about your clinic visit:

Thank you for your feedback!

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