Consumer Satisfaction Survey

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* 1. Hnub no (Today's Date):

Date

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* 2. Thov khij hauv qab no seb lub chaw twg yog lub lawv ntsib koj dua lawm:

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* 3. Ua koj tau txais cov kev pab hom twg lawm?

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* 4. Yog koj tau txais cov kev pab nyob hauv TSEV KHO NYUAB SIAB NTXHOV PLAWV lawm no, koj khij seb koj mus koom nrog pawg twg.

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* 5. Yog koj tau txais kev pab hauv TXIAV YEEB TSHUAJ los yog DEJ CAWS no, thov koj khij hauv qab no seb yog koj koom nrog pawg twg.

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* 6. Koj yog hom twg (Gender):

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* 7. Nyiam deev nrog (Sexual Orientation):

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* 8. Hom Neeg (Race/Ethnicity):

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* 9. Hnub Nyoog Nyob Ncua (Age):

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* 10. Txoj kev pab cuam no nws yooj yim (Ease of Use):

Yog kawg li Yog Tsis yog Tsis yog kiag li Tsis paub Tsis muaj
1. Nws yooj yim rau teem caij mus ntsib. 
2. Qhov chaw mus nrhiav kev pab cuam yoojyim heev.
3. Kuv tau txais cov kev pab cuam raws li qhov kuv xav tau.
4. Kev pab cuam muaj rau lub sijhawm haum rau kuv.
5. Cov tub khiav dejnum hu xovtooj rov rau kuv tsis tshaj 24 teev.

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* 11. Kev kho (Quality of Care):

Yog kawg li Yog Tsis yog Tsis yog kiag li Tsis paub Tsis muaj
6. Cov tub khiav dejnum fwm thiab mloog txog kuv tej teebmeem.
7. Kuv totaub txog qhov lawv yuav pab kho kuv.
8. Kuv tso siab hlo nug txog tej kev kho kuv thiab tej tshuaj kuv noj.
9. Kuv koom tawm tswvyim txog txoj kev npaj yuav kho kuv.

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* 12. Pab tau (Outcomes):

Yog kawg li Yog Tsis yog Tsis yog kiag li Tsis paub Tsis muaj
10. Nws pab tau kuv nyob kaj siab zog.
11. Nws pab tau kuv raws li lub siab xav.
12. Kuv rov ua (leg) tau tej yam uas niaj hnub ua lawm thiab.

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* 13. Xam tag nrho ces yeej txaus siab (Overall Satisfaction):

Yog kawg li Yog Tsis yog Tsis yog kiag li Tsis paub Tsis muaj
13. Kuv txaus siab qhia txoj kev pab cuam ntawm lub chaw nov rau kuv tsev neeg los yog kuv cov phoojywg kom lawv paub txog.
14. Yog muaj lwm qhov es cia kuv xaiv, kuv tseem yuav rov tuaj nrhiav kev pab cuam ntawm lub chaw nov.
Ua tsaug rua koj qhia peb, kom peb paub ua hauj lwm zoo mus ntxiv!

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