What is your gender?

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* 1. What is your gender?

What is your age?

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* 2. What is your age?

How many people currently live in your household?

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* 3. How many people currently live in your household?

What is your approximate average household income?

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* 4. What is your approximate average household income?

Have you ever received services at Mid-Valley Hospital?

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* 5. Have you ever received services at Mid-Valley Hospital?

How would you describe your overall experience?

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* 6. How would you describe your overall experience?

How satisfied were you with the skill and competency of the staff at Mid-Valley Hospital?

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* 7. How satisfied were you with the skill and competency of the staff at Mid-Valley Hospital?

  Extremely Satisfied Satisfied Neutral Dissatisfied Extremely Dissatisfied N/a
Admitting Desk Staff
Housekeeping Staff
Food Services Staff
Nurses
Physicians Assistants
Radiology Technicians
Laboratory Technicians
Doctors 
Surgeons
Have you ever received care at Mid-Valley Clinic?

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* 8. Have you ever received care at Mid-Valley Clinic?

How would you describe your overall experience at Mid-Valley Clinic?

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* 9. How would you describe your overall experience at Mid-Valley Clinic?

  Very Positive Positive Neutral Negative Very Negative N/A
Cleanliness
Staff Friendliness
Competency of Medical Care Team Staff
Services Offered
Are you familiar with Mid-Valley Hospital's services? (Please check the box next to those that you are aware of)

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* 10. Are you familiar with Mid-Valley Hospital's services? (Please check the box next to those that you are aware of)

Are you familiar with Mid-Valley Clinic's services?

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* 11. Are you familiar with Mid-Valley Clinic's services?

Are you familiar with Mid-Valley Hospital's Physical Therapy Services? (Please check the boxes next to the services you are aware of.)

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* 12. Are you familiar with Mid-Valley Hospital's Physical Therapy Services? (Please check the boxes next to the services you are aware of.)

Why do you choose Mid-Valley Hospital & Clinic? (Please choose your number one reason)

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* 13. Why do you choose Mid-Valley Hospital & Clinic? (Please choose your number one reason)

If you choose to seek care out of town, why do you do so? (Please check all that apply.)

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* 14. If you choose to seek care out of town, why do you do so? (Please check all that apply.)

If you have chosen to seek care out of town, for which services have you gone elsewhere?

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* 15. If you have chosen to seek care out of town, for which services have you gone elsewhere?

If you choose to seek Primary Care elsewhere, where do you go?

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* 16. If you choose to seek Primary Care elsewhere, where do you go?

What is your perception of Mid-Valley Hospital & Clinic's reputation in the community? Please answer even if you have not received services from us.

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* 17. What is your perception of Mid-Valley Hospital & Clinic's reputation in the community? Please answer even if you have not received services from us.

If a local healthcare provider wanted to communicate information about any updates to services and programs to you, what would be your most preferred method of receiving that information? (Please check all that apply)

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* 18. If a local healthcare provider wanted to communicate information about any updates to services and programs to you, what would be your most preferred method of receiving that information? (Please check all that apply)

At Mid-Valley Hospital & Clinic, our goal is to continually improve our services and patient care. We value your opinion. Do you have any comments, praise or suggestions to share with the Mid-Valley staff?

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* 19. At Mid-Valley Hospital & Clinic, our goal is to continually improve our services and patient care. We value your opinion. Do you have any comments, praise or suggestions to share with the Mid-Valley staff?

What is your zipcode?

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* 20. What is your zipcode?

Would you be interested in being a part of a newly formed Patient & Family Advisory Council?

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* 21. Would you be interested in being a part of a newly formed Patient & Family Advisory Council?

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