Consumer Satisfaction Survey

Evaluation Survey

25% of survey complete.

Thank you for answering this survey. It is used in part to evaluate staff and also make improvements in the program.

Question Title

* 1. Your Name (Optional)

Question Title

* 2. Most Recent Date of Service

Date of service

Date

Question Title

* 3. Clinician's Name or Department seen by

Question Title

* 4. Your Clinician or Department seen by

	Needs Improvement	Fair	Average	Very Good	Excellent	N/A
Staff knowledge and skills	Staff knowledge and skills Needs Improvement	Staff knowledge and skills Fair	Staff knowledge and skills Average	Staff knowledge and skills Very Good	Staff knowledge and skills Excellent	Staff knowledge and skills N/A
Explanations of test results and recommendations	Explanations of test results and recommendations Needs Improvement	Explanations of test results and recommendations Fair	Explanations of test results and recommendations Average	Explanations of test results and recommendations Very Good	Explanations of test results and recommendations Excellent	Explanations of test results and recommendations N/A
Quality of report	Quality of report Needs Improvement	Quality of report Fair	Quality of report Average	Quality of report Very Good	Quality of report Excellent	Quality of report N/A
Staff listened and communicated well	Staff listened and communicated well Needs Improvement	Staff listened and communicated well Fair	Staff listened and communicated well Average	Staff listened and communicated well Very Good	Staff listened and communicated well Excellent	Staff listened and communicated well N/A
Staff considered my input	Staff considered my input Needs Improvement	Staff considered my input Fair	Staff considered my input Average	Staff considered my input Very Good	Staff considered my input Excellent	Staff considered my input N/A