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Immediate Care survey

We thank you in advance for completing this questionnaire. When you are finished please click the submit button once.

Background Questions
1. Date of Visit: 4. Time spent at the Care Center:

2. Time of day you arrived: (select one option only)



 5. Patient's Sex:
6. Patient's age: Years.
3. On what day was your most recent visit?

7. Who is filling out this survey?
Patient           Friend
Parent          
Family

A. ARRIVAL
Very Poor
Poor
Fair
Good
Very Good
1. Comfort of the waiting area
2. Waiting time before you were brought to the treatment area
3. Waiting time in the treatment area, before you were seen by a doctor
Comments (describe good or bad experience)
B. NURSES
Very Poor
Poor
Fair
Good
Very Good
1. Courtesy of the nurses
2. Degree to which the nurses took the time listen to you
3. Nurses' attention to your needs
4. Nurses' concern to keep you informed about your treatment
5. Nurses' concern for your privacy
Comments (describe good or bad experience)
C. DOCTORS
Very Poor
Poor
Fair
Good
Very Good
1. Courtesy of the doctor
2. Degree to which the doctor took the time listen to you
3. Doctor's concern to keep you informed about your treatment
4. Doctor's concern for your comfort while treating you
Comments (describe good or bad experience)
D. TESTS
Very Poor
Poor
Fair
Good
Very Good
1. Courtesy of the person who took your blood
2. Concern shown for your comfort when your blood was drawn
E. FAMILY OR FRIENDS
Very Poor
Poor
Fair
Good
Very Good
1. Courtesy with which your family or friends were treated
2. Staff concern to keep family or friends informed about your status during your course of treatment
3. Staff concern to let a family member or friend be with you while you were being treated
Comments (describe good or bad experience)
F. PERSONAL / INSURANCE INFORMATION
Very Poor
Poor
Fair
Good
Very Good
1. Courtesy of the person who took your personal/insurance information
2. Privacy you felt when asked about your personal/insurance information
3. Ease of giving your personal/insurance information
Comments (describe good or bad experience)
G. PERSONAL ISSUES
Very Poor
Poor
Fair
Good
Very Good
1. How well you were kept informed about delays
2. Degree to which staff cared about you as a person
3. How well your pain was controlled
4. Information you were given about caring for yourself at home (e.g., taking medications, getting follow-up medical care)
5. Cleanliness of the Immediate Care Center
Comments (describe good or bad experience)
H. OVERALL ASSESSMENT
Very Poor
Poor
Fair
Good
Very Good
1. Overall rating of care received during your visit
2. Likely hood of your recommending our Immediate Care Center to others
3. Safety and security you felt in the Immediate Care Center
4. Your confidence that staff provided care in a safe manner
Comments (describe good or bad experience)
How could we improve our services?
How can SIC improve patient safety?
 
   

If you feel that you may have a life-threatening condition that requires emergency care, call "911"
or go to the nearest hospital-based emergency room.