Public Healthcare Services Survey
Exit this survey
*
1
. I am
I am
Deaf
Hard of Hearing
DeafBlind
Other (please specify)
*
2
. I live in the city of
I live in the city of
*
3
. Have you ever experienced communication barriers at a hospital or clinic?
Have you ever experienced communication barriers at a hospital or clinic?
Yes
No
4
. If you answered yes, when and where? (Hospital/Clinic name and year)
If you answered yes, when and where? (Hospital/Clinic name and year)
*
5
. Please rate your communication experience during your visit
Excellent
Satisfactory
Fair
Poor
My communication experience was
*
Please rate your communication experience during your visit My communication experience was Excellent
My communication experience was Satisfactory
My communication experience was Fair
My communication experience was Poor
*
6
. Did you request accommodations? (Interpreters, Captions, etc.)
Did you request accommodations? (Interpreters, Captions, etc.)
Yes
No
7
. If yes, what was your request? (mark all that apply)
If yes, what was your request? (mark all that apply)
On-Site Licensed Interpreters
Captioned Phone
Video Remote Interpreting (VRI)
Video Phone
Pocketalker
TV Closed Captions
Amplified Phone
FM System
Signaling Devices
TTY
Other (please specify)
*
8
. Were your needs met?
Were your needs met?
Yes
No
9
. If no, please explain
If no, please explain
10
. (Optional) Your Name and Contact Information
(Optional) Your Name and Contact Information
Powered by
SurveyMonkey
Create your own
free online survey
now!
Javascript is required for this site to function, please enable.