Patient Survey

1
Patient Survey Please take a moment to complete
our Patient Survey. All clinic patients will be
surveyed after each scheduled follow-up
appointment. Your opinions are important to us!
We strive to provide the best care possible to
all of our patients. Only our patients can let
us know how we are doing! This survey is
confidential. Place in the designated reply box
when you have completed or return to us in the
provided envelope. The replies will be handled
and tabulated by non-clinical staff and will, in
no way, affect your treatment or care.
Date of clinic visit__________________ Please
rate your over-all clinic experience TODAY by
circling the number Poor Fair OK
Good Excellent 1------------
--2----------------3--------------4---------------
-5 Please indicate any specific problems you had
today with the clinic, the facility, or
staff Were all your questions answered to your
satisfaction? ( ) Yes ( ) No Other
Comments
2
(No Transcript)
3
University of Nebraska Medical Center HIV Program
Quality Management Program Quality
Committee Performance Improvement Plan Report
Start Date_____________________
November 1, 2002
Report submitted by______________________________
_____Date______________ July 2003