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Professional - CPAP Therapy Referral Survey

 

*

1. Please check which of the following describes your location the best:

Please check which of the following describes your location the best:   Hospital Hospital Sleep Lab Private Sleep Lab Family Physician

Other Comments

2. I prescribe CPAP Therapy and am a:

I prescribe CPAP Therapy and am a:   Sleep Physician Respirologist Other Specialist Family Physician

Other (please specify)

3. I recommend CPAP providers to patients and I am a:

I recommend CPAP providers to patients and I am a:   Sleep Physician Respirologist Other Specialist Family Physician Healthcare Professional (RPSGT/RRT/RN) Other

Other (please specify)

4. I practice in the following Province

I practice in the following Province   BC AB SK MB ON QC NB NS PEI NL

5. Please rate the importance of the following when recommending a CPAP Provider:

	Not Important	Somewhat Important	Neutral	Very Important	Extremely Important
Range of CPAP products provided	*Please rate the importance of the following when recommending a CPAP Provider: Range of CPAP products provided Not Important	Range of CPAP products provided Somewhat Important	Range of CPAP products provided Neutral	Range of CPAP products provided Very Important	Range of CPAP products provided Extremely Important
Ease of contact and response time	Ease of contact and response time Not Important	Ease of contact and response time Somewhat Important	Ease of contact and response time Neutral	Ease of contact and response time Very Important	Ease of contact and response time Extremely Important
Optimizing patient comfort (mask fitting)	Optimizing patient comfort (mask fitting) Not Important	Optimizing patient comfort (mask fitting) Somewhat Important	Optimizing patient comfort (mask fitting) Neutral	Optimizing patient comfort (mask fitting) Very Important	Optimizing patient comfort (mask fitting) Extremely Important
Educational materials including what is OSA, benefits of CPAP, importance of compliance, hygiene and safety	Educational materials including what is OSA, benefits of CPAP, importance of compliance, hygiene and safety Not Important	Educational materials including what is OSA, benefits of CPAP, importance of compliance, hygiene and safety Somewhat Important	Educational materials including what is OSA, benefits of CPAP, importance of compliance, hygiene and safety Neutral	Educational materials including what is OSA, benefits of CPAP, importance of compliance, hygiene and safety Very Important	Educational materials including what is OSA, benefits of CPAP, importance of compliance, hygiene and safety Extremely Important
Access to professional staff	Access to professional staff Not Important	Access to professional staff Somewhat Important	Access to professional staff Neutral	Access to professional staff Very Important	Access to professional staff Extremely Important
Experience and expertise of provider	Experience and expertise of provider Not Important	Experience and expertise of provider Somewhat Important	Experience and expertise of provider Neutral	Experience and expertise of provider Very Important	Experience and expertise of provider Extremely Important
National Accreditation	National Accreditation Not Important	National Accreditation Somewhat Important	National Accreditation Neutral	National Accreditation Very Important	National Accreditation Extremely Important
Actively follow patients to improve compliance (6 month follow up)	Actively follow patients to improve compliance (6 month follow up) Not Important	Actively follow patients to improve compliance (6 month follow up) Somewhat Important	Actively follow patients to improve compliance (6 month follow up) Neutral	Actively follow patients to improve compliance (6 month follow up) Very Important	Actively follow patients to improve compliance (6 month follow up) Extremely Important
Sending reports back to Physician	Sending reports back to Physician Not Important	Sending reports back to Physician Somewhat Important	Sending reports back to Physician Neutral	Sending reports back to Physician Very Important	Sending reports back to Physician Extremely Important

Other (please specify)