Exit Outpatient Ratings Quarter 1 2018 Question Title * 1. What is the patient's LAST name? Question Title * 2. What is the patient's FIRST name? Question Title * 3. What month did you begin therapy? January February March April May June July August September October November December Question Title * 4. Where did you receive your treatment? Cape May Court House Ocean City Marmora North Cape May Tuckerton Manahawkin Atlantic City Brigantine Egg Harbor Township Pomona (Main Campus) Galloway (Galloway Tilton Fitness) Hammonton Linwood Margate Mays Landing Somers Point Vineland Question Title * 5. Please check what outpatient service(s) you received at Bacharach. Audiology/ Hearing Aid Cardiac/ Pulmonary Driving Program Occupational Therapy Psychology Physician Services Physical Therapy Pool Therapy Sleep Disorders Center Speech Language Pathology Other (please specify) Question Title * 6. Ease of making appointment by phone Poor Fair Average Good Excellent N/A Poor Fair Average Good Excellent N/A Question Title * 7. Length of time you had to wait between making an appointment and your initial visit Poor Fair Average Good Excellent N/A Poor Fair Average Good Excellent N/A Question Title * 8. Ease of locating the treatment area Poor Fair Average Good Excellent N/A Poor Fair Average Good Excellent N/A Question Title * 9. Availability/ Convenience of Parking Poor Fair Average Good Excellent N/A Poor Fair Average Good Excellent N/A Question Title * 10. Availability of transportation services Poor Fair Average Good Excellent I did not use a transportation service Poor Fair Average Good Excellent I did not use a transportation service Question Title * 11. If you used transportation services was it through Bacharach or the County? Bacharach County Other (please specify) Question Title * 12. Waiting time in treatment area (arrival to start of treatment) Poor Fair Average Good Excellent N/A Poor Fair Average Good Excellent N/A Question Title * 13. Environment of treatment area (clean, safe organized) Poor Fair Average Good Excellent N/A Poor Fair Average Good Excellent N/A Question Title * 14. Courtesy of therapists/ staff Poor Fair Average Good Excellent N/A Poor Fair Average Good Excellent N/A Question Title * 15. Staff involving you in treatment and goal setting Poor Fair Average Good Excellent N/A Poor Fair Average Good Excellent N/A Question Title * 16. Staff willingness to answer questions Poor Fair Average Good Excellent Poor Fair Average Good Excellent Question Title * 17. Reached expected level of improvement as result of services Poor Fair Average Good Excellent Poor Fair Average Good Excellent Question Title * 18. Overall satisfaction of services your received Poor Fair Average Good Excellent Poor Fair Average Good Excellent Question Title * 19. Likelihood of you recommending services to others Poor Fair Average Good Excellent Poor Fair Average Good Excellent Question Title * 20. Approximately how many times (days) were you here for treatment? Question Title * 21. Did you witness your therapist washing their hands between patients? Yes No N/A Question Title * 22. Is there anything you would like to tell us about our services? Please include suggestions for improvement of our services. Question Title * 23. Relationship to Patient Self Spouse Child Parent Other Other (please specify) Done
