Outpatient Satisfaction Survey

1. Was the registration easy to complete?

Never

Sometimes

Usually

Always

2. Was the manner of the person who registered you courteous, respectful, and sensitive?

Never

Sometimes

Usually

Always

3. Was the waiting time before you were called to your outpatient service appropriate?

Never

Sometimes

Usually

Always

4. Was the area clean and free of clutter?

Never

Sometimes

Usually

Always

5. Was the equipment in working order?

Never

Sometimes

Usually

Always

6. Was the noise level in the area kept to a minimum?

Never

Sometimes

Usually

Always

7. Was the room temperature comfortable?

Never

Sometimes

Usually

Always

8. Was the manner of the staff courteous, respectful, and sensitive?

Never

Sometimes

Usually

Always

9. Was the staff thorough, careful, and knowledgeable in their performance of the procedure?

Never

Sometimes

Usually

Always

10. Using any number 0 to 10, where 0 is the worst hospital possible and 10 the best hospital possible, what number would you use to rate this hospital during your visit?

0

1

2

3

4

5

6

7

8

9

10

11. Would you recommend this hospital to your friends and family?

Definitely no

Probably no

Probably yes

Definitely yes

12. In general, how would you rate your overall health?

Excellent

Very Good

Good

Fair

Poor

13. What is the highest grade or level of school that you have completed?

8th grade or less

Some high school, but did not graduate

High school graduate or GED

Some college or 2-year degree

4-year college graduate

More than 4-year college degree

14. Are you of Spanish, Hispanic, or Latino origin or descent?

No, not Spanish/Hispanic/Latino

Yes, Puerto Rican

Yes, Mexican/Mexican American/Chicano

Yes, Cuban

Yes, other Spanish/Hispanic/Latino

15. What is your race?

Please choose one or more.

Caucasian

African-American

Asian

Native American or other Pacific Islander

American Indian or Alaska Native

16. What language do you mainly speak at home?

English

Spanish

Chinese

Russian

Vietnamese

Other (Please answer question 17)