Health Center Evaluation Survey

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1. Gender

Gender Male

Female

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2. Enrollment Status

Enrollment Status Undergraduate

Graduate

Non-degree

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3. Amount of time needed in the health service to complete your appointment:

	very satisfied				very dissatisfied
satisfaction	*Amount of time needed in the health service to complete your appointment: satisfaction very satisfied	satisfaction	satisfaction	satisfaction	satisfaction very dissatisfied

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4. Amount of time needed in the health service to complete your appointment:

	Y	N
Waited too long to complete registration (i.e. check in upon arrival)	*Amount of time needed in the health service to complete your appointment: Waited too long to complete registration (i.e. check in upon arrival) Y	Waited too long to complete registration (i.e. check in upon arrival) N
Waited too long to be placed in an examination room	Waited too long to be placed in an examination room Y	Waited too long to be placed in an examination room N
Waited too long for the provider	Waited too long for the provider Y	Waited too long for the provider N

5. Were you sent to the doctor? If yes, which doctor did you see:

Were you sent to the doctor? If yes, which doctor did you see: Y

Dr. Merkle

Dr. Howard

6. Quality of the explanation and advice you were given for your condition and the recommended treatment: (select all that apply)

Quality of the explanation and advice you were given for your condition and the recommended treatment: (select all that apply) I understood the explanation given for my condition

I felt confident in the explanation of my condition

I understood the treatment plan

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7. I received information during my visit that I will use to improve my health.

	Strongly agree				Strongly disagree
Agreement	*I received information during my visit that I will use to improve my health. Agreement Strongly agree	Agreement	Agreement	Agreement	Agreement Strongly disagree

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8. Your confidentiality and privacy were carefully protected:

	Very satisfied				Very dissatisfied
Satisfaction	*Your confidentiality and privacy were carefully protected: Satisfaction Very satisfied	Satisfaction	Satisfaction	Satisfaction	Satisfaction Very dissatisfied

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9. Did your health care provider wash his/her hands or use an alcohol based hand sanitizer?

Did your health care provider wash his/her hands or use an alcohol based hand sanitizer? Yes

Not sure

Not applicable

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10. Your overall satisfaction with your visit:

	Very satisfied				Very dissatisfied
Satisfaction	*Your overall satisfaction with your visit: Satisfaction Very satisfied	Satisfaction	Satisfaction	Satisfaction	Satisfaction Very dissatisfied

Health Center Evaluation
Exit this survey

1. Default Section

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1. Gender

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2. Enrollment Status

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3. Amount of time needed in the health service to complete your appointment:

*
4. Amount of time needed in the health service to complete your appointment:

5. Were you sent to the doctor? If yes, which doctor did you see:

6. Quality of the explanation and advice you were given for your condition and the recommended treatment: (select all that apply)

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7. I received information during my visit that I will use to improve my health.

*
8. Your confidentiality and privacy were carefully protected:

*
9. Did your health care provider wash his/her hands or use an alcohol based hand sanitizer?

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10. Your overall satisfaction with your visit:

Health Center EvaluationExit this survey

1. Default Section

*1. Gender

*2. Enrollment Status

*3. Amount of time needed in the health service to complete your appointment:

*4. Amount of time needed in the health service to complete your appointment:

5. Were you sent to the doctor? If yes, which doctor did you see:

6. Quality of the explanation and advice you were given for your condition and the recommended treatment: (select all that apply)

*7. I received information during my visit that I will use to improve my health.

*8. Your confidentiality and privacy were carefully protected:

*9. Did your health care provider wash his/her hands or use an alcohol based hand sanitizer?

*10. Your overall satisfaction with your visit:

Health Center Evaluation
Exit this survey

*
1. Gender

*
2. Enrollment Status

*
3. Amount of time needed in the health service to complete your appointment:

*
4. Amount of time needed in the health service to complete your appointment:

*
7. I received information during my visit that I will use to improve my health.

*
8. Your confidentiality and privacy were carefully protected:

*
9. Did your health care provider wash his/her hands or use an alcohol based hand sanitizer?

*
10. Your overall satisfaction with your visit: