Survey

Your Feedback on LMV Clinic Operations

By default, your responses to the short survey below are anonymous. If you've forgotten details about the clinic experience... no worries... simply skip the question or respond Not Applicable (N/A) and move on. Only those questions prefaced with an asterisk (*) are required.

After you've responded to the questions, make sure to scroll all the way to the bottom and click Submit Survey.

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1. Clinic Location (city, state or country)

Clinic Location (city, state or country)

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2. When was the starting date of this LMV Clinic?

	MM		DD		YYYY
Clinic Start Date	When was the starting date of this LMV Clinic? Clinic Start Date Month	/	Day	/	Year

3. To date I've participated in the following number of LMV clinics:

To date I've participated in the following number of LMV clinics:

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4. What is your Overall evaluation of Clinic Operations with regard to:

	Poor	Fair	Good	Very Good	Outstanding	N/A
Planning & Communication	*What is your Overall evaluation of Clinic Operations with regard to: Planning & Communication Poor	Planning & Communication Fair	Planning & Communication Good	Planning & Communication Very Good	Planning & Communication Outstanding	Planning & Communication N/A
Setup	Setup Poor	Setup Fair	Setup Good	Setup Very Good	Setup Outstanding	Setup N/A
Patient Intake	Patient Intake Poor	Patient Intake Fair	Patient Intake Good	Patient Intake Very Good	Patient Intake Outstanding	Patient Intake N/A
Patient Education	Patient Education Poor	Patient Education Fair	Patient Education Good	Patient Education Very Good	Patient Education Outstanding	Patient Education N/A
Clinic Productivity	Clinic Productivity Poor	Clinic Productivity Fair	Clinic Productivity Good	Clinic Productivity Very Good	Clinic Productivity Outstanding	Clinic Productivity N/A
Overall	Overall Poor	Overall Fair	Overall Good	Overall Very Good	Overall Outstanding	Overall N/A

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5. Would you recommend to a friend or family member that they participate in future similar LMV Clinics?

Would you recommend to a friend or family member that they participate in future similar LMV Clinics? No

Maybe

Yes

Absolutely

The remaining questions (answers optional, but very much appreciated) ask for more specific information about your clinic experience. The more we understand the better we can do next time. We'd love to get your detailed feedback, but if you'd prefer, you can skip to the end and Submit your survey.

For the following questions, please provide a brief narrative on your thoughts and feedback. Sample questions have been listed for each topic but we encourage you to write or list any observations.

6. Planning & Communication: e.g. Were you well-informed on logistics or preparations for the clinic? Could additional actions have been taken in advance to improve the experience? Any suggestions for improving the process for online trip sign up?

Planning & Communication: e.g. Were you well-informed on logistics or preparations for the clinic? Could additional actions have been taken in advance to improve the experience? Any suggestions for improving the process for online trip sign up?

7. Setup: e.g. What equipment did you bring? Which LMV materials did you use? What kind of LMV set up would make (or has made) your work quicker, easier, more effective? Are there things that worked particularly well on this trip? Problems that you noticed?

Setup: e.g. What equipment did you bring? Which LMV materials did you use? What kind of LMV set up would make (or has made) your work quicker, easier, more effective? Are there things that worked particularly well on this trip? Problems that you noticed?

8. Patient Intake: e.g. Were there bottlenecks? Did we collect the right information (how useful was it in directing patients or for pre-care)? Are there changes you would suggest? How can we improve the queuing for patients with multiple health visits during the day?

Patient Intake: e.g. Were there bottlenecks? Did we collect the right information (how useful was it in directing patients or for pre-care)? Are there changes you would suggest? How can we improve the queuing for patients with multiple health visits during the day?

9. Patient Education: e.g. Which critical areas for public education would you address? Do you have ideas for more teaching opportunities during the clinic?

Patient Education: e.g. Which critical areas for public education would you address? Do you have ideas for more teaching opportunities during the clinic?

10. Clinic Productivity: e.g. What was good about the experience? Did you need anything you did not have? Did the work flow well or not? Why? Could we have seen more patients? Provided additional services? What kinds of care did most of your patients need? Ideas for addressing those common complaints? Preventive care? Suggestions?

Clinic Productivity: e.g. What was good about the experience? Did you need anything you did not have? Did the work flow well or not? Why? Could we have seen more patients? Provided additional services? What kinds of care did most of your patients need? Ideas for addressing those common complaints? Preventive care? Suggestions?

11. Please provide additional feedback by entering specific points about the above or any other critique of the LMV clinic operations. Please include comments about what you liked about the experience as well as what you think we could do to make future experiences more productive and enjoyable.

Please provide additional feedback by entering specific points about the above or any other critique of the LMV clinic operations. Please include comments about what you liked about the experience as well as what you think we could do to make future experiences more productive and enjoyable.

12. (optional) Your name and contact info

(optional) Your name and contact info Name:
Email:
Phone Number:

Don't forget to click Submit Survey below. Thank you and come back often to provide your feedback on other LMV clinics.