Patient Satisfaction Web Survey - Immunization

This brief patient satisfaction survey is for persons who received services in any of The City of New York Immunization Clinics. The New York City Department of Health and Mental Hygiene wants to know how well they are satisfying their patients and where they should make improvements. Your honest feedback is very important.

Please be assured that your individual responses to the survey will be confidential and will only be shared with the New York City Department of Health and Mental Hygiene for the purposes of improving the quality of patient care and not for sales, marketing or fund raising. The goal of this survey is to improve services for patients.

As we go though the survey, please rate your experiences in this clinic only during your most recent visit, even if you had other services. Lets begin.

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* CQMI Number           (For Office Use Only)

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* 1. What is the date of your most recent clinic visit?

Date

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* 2. What is your age range?

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* 3. What is your gender at birth?

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* 4. From beginning to end, how long was your overall or total time in the clinic? Would you say...

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* 5. Were you given an explanation for the delay?

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* 6. Did you find the following area(s) clean:

  Yes No Does Not Apply
Waiting area(s)?
Examination room(s)?
Bathroom(s)?

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* 7. Did you receive a vaccination at the clinic?

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* 8. Did the patient care staff explain what the vaccination is for?

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* 9. Did you have any fears or concerns associated with going to the clinic?

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* 10. Did you have any fears or concerns associated with getting a vaccine?

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* 11. If yes, did the clinician explain what the vaccine was for?

Using any number from 1 to 5, where 1 is the worst possible option and 5 is the best possible option, please rate each of the clinical service throughout your clinic visit

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* 12. What number would you use to rate the health care professionals who cared for you?

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* 13. In your opinion, did the clinic keep your personal health information private?

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* 14. Did you need language interpretation services?

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