Provider & Clinical Facilitator (Distant Site) Survey Form

Please do NOT include any Patient Protected Health Information (PHI) on this survey

Question Title

* 1. Care via Telehealth is an important service offered by SHC.

Question Title

* 2. Patient's chief complaint or condition was evident during exam.

Question Title

* 3. Telehealth exam allowed me to provide necessary patient care.

Question Title

* 4. All relevant data needed to make clinical decisions was available.

Question Title

* 5. Clinical team at the affiliate effectively used the telehealth equipment.

Question Title

* 6. Quality of Visual Image

Question Title

* 7. Quality of Audio (sound)

Question Title

* 8. Telehealth session duration was adequate. 

Question Title

* 9. Telehealth system was accessible and easy to use.

Question Title

* 10. Overall Rating of this Telehealth Experience

Question Title

* 11. Please provide any suggestions to Improve the Telehealth Consult or any additional comments.

Question Title

* 12. Date & Time of Clinic

Date
Time

Question Title

* 13. SHC Hospital

Question Title

* 14. Your Role

Question Title

* 15. Your Name (Optional) 

T