Exhibit R - JOES_Survey_Adult_202309_Child_202309.pdf
PDF 363 KB Posted
- Solicitation number
- HT001524R0030
- Issued by
-
Defense Health Agency
About this file
This document contains a survey for patients and their guardians regarding care received at a military medical facility. The survey collects feedback on a recent visit with specific providers, experiences with various services, and overall satisfaction. Questions address courtesy of staff, quality of explanations, trust in providers, time spent with patients, and availability of appointments. The related federal contract opportunity is for services at the AT Augusta Military Medical Center Ambulatory Care Center. The solicitation number is HT001524R0030 and it involves the Defense Health Agency.
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1. According to our records, you recently had a healthcare visit with RANK PROVIDER NAME on DATE at FACILITY NAME in the PRIMARY CARE CLINICS department.
Is this correct?
Yes .................................................................................. Please continue with survey.
No, saw someone else (Specify) ___________________ Please go to question #12.
No, didn’t have visit ......................................................... Please return your survey in the pre-paid envelope provided.
Thinking specifically about this visit, please mark an “X” in the box for the answer that applies to you:
2. Do you know who your Primary Care Manager (PCM) is?
Yes No Currently do not have a PCM
3. Did you see your PCM during this visit (Please pick one answer)?
Yes No, I saw another provider from a different care team
No, I saw another provider on my care team No, I saw a specialty provider or Emergency Department
For questions 4 through 8, please indicate how much you agree or disagree with the following statements:
Strongly
Disagree
Somewhat
Disagree
Neither Agree nor Disagree
Somewhat
Agree
Strongly
Agree
4. This provider, RANK PROVIDER NAME, treated me with courtesy and respect
5. This provider explained things in a way that was easy to understand
6. This provider seemed to know the important information about my medical history
7. This provider spent the time with me that my medical needs required
8. I trust my provider to give me the care that I need
For question 9, please indicate how satisfied or dissatisfied you are with the following:
Completely
Dissatisfied
Somewhat
Dissatisfied
Neither Satisfied nor Dissatisfied
Somewhat
Satisfied
Completely
Satisfied
9. Overall, how satisfied are you with your visit with this provider?
10. Did this provider review a complete list of your current and new medications with you, including any over-the-counter medications (e.g. aspirin, vitamins)? ....... ... Yes No N/A
11. Please provide any comments about your visit with RANK PROVIDER NAME that you would like to share. Please do not provide any personally identifiable information.
12. If you made an appointment for this visit, how did you make this appointment?
Phone 12a. When making this appointment, were you at any time told no appointments were available but to call back when they would be available? .................. Yes No
Patient Portal (TRICARE Online, MHS
Genesis Patient Portal) In Person
No, did not make appointment (ER, walk-in, someone else made appointment for me, etc.)
Please use pen or dark pencil to mark an “X” in the answer box:
Example: Correct Incorrect
LICENSE TO ADMINISTER: Report
RCS: DD-HA (D) 2598
Expires: June 30, 2025
For questions 13 through 15, please rate the following aspects of your appointment:
13. How did you receive care during this visit?
In person Via video visit Via telephone (audio only) Via email/secure messaging
N/A Poor Fair Good Very Good Excellent
14. If seen past your scheduled appointment time, the effort made to keep you informed about the delay. ..
15. Did your healthcare team begin to address your needs within 30 minutes of your appointment time?
Yes No N/A
For questions 16 and 17, please rate the following aspects of your care and service during THIS visit:
N/A Poor Fair Good Very Good Excellent
16. The courtesy and respectfulness of clerks and receptionists
17. The helpfulness of clerks and receptionists If you also went to the Pharmacy, Laboratory, or Radiology Department in conjunction with THIS visit, please rate your experience with these services:
N/A Poor Fair Good Very Good Excellent
18. Overall experience with Pharmacy
19. Overall experience with Radiology
20. Overall experience with Laboratory
Please indicate how much you agree or disagree with the following statements:
Strongly
Disagree
Somewhat
Disagree
Neither
Agree nor
Disagree
Somewhat
Agree
Strongly
Agree
21. Overall, I am satisfied with the healthcare I received on this visit
22. I would recommend this facility to a TRICARE-eligible family member or friend ........................................................................... …
23. In general, I am able to see my provider when needed About you:
Poor Fair Good Very Good Excellent
24. In general, how would you rate your overall health?
25.
In general, how would you rate your overall mental or emotional health?
26. Please provide any comments about FACILITY NAME that you would like to share. Please do not provide any personally identifiable information.
Thank you very much for your opinions. Please return your questionnaire in the envelope provided to:
ATTN: MILITARY HEALTH SYSTEM SURVEY CENTER, c/o Ipsos, P.O. BOX 5030, CHICAGO, IL 60680-9858
Privacy Advisory: Your contact information was used to ask for your participation in this survey about your recent visit. Your responses are voluntary and your decision to participate or not will not affect your opportunity to receive future medical benefits. However, your responses to this survey about your recent experience in our treatment facility will allow us to maintain or improve the quality of the patient care provided to all receiving treatment at your facility. Please note, if during this survey you indicate a direct threat to harm yourself or others, we are required to forward information about that threat to appropriate authorities for action, which will likely include their contacting you.
1. According to our records, your child recently had a healthcare visit with RANK PROVIDER NAME on DATE at FACILITY NAME in the PRIMARY CARE CLINICS department.
Is this correct?
Yes .................................................................................. Please continue with survey.
No, saw someone else (Specify) ___________________ Please go to question #12.
No, didn’t have visit ......................................................... Please return your survey in the pre-paid envelope provided.
Thinking specifically about this visit, please mark an “X” in the box for the answer that applies to you:
2. Do you know who your child’s Primary Care Manager (PCM) is?
Yes No Currently do not have a PCM
3. Did you see your child’s PCM during this visit (Please pick one answer)?
Yes No, saw another provider from a different care team
No, saw another provider on my care team No, saw a specialty provider or Emergency Department
For questions 4 through 8, please indicate how much you agree or disagree with the following statements:
Strongly
Disagree
Somewhat
Disagree
Neither Agree nor Disagree
Somewhat
Agree
Strongly
Agree
4. This provider, RANK PROVIDER NAME, treated my child with courtesy and respect
5. This provider explained things in a way that was easy to understand
6. This provider seemed to know the important information about my child’s medical history
7. This provider spent the time with my child that my child’s medical needs required
8. I trust my child’s provider to give my child the care that they need
For question 9, please indicate how satisfied or dissatisfied you are with the following:
Completely
Dissatisfied
Somewhat
Dissatisfied
Neither Satisfied nor Dissatisfied
Somewhat
Satisfied
Completely
Satisfied
9. Overall, how satisfied are you with your child’s visit with this provider?
10. Did this provider review a complete list of your child’s current and new medications with you, including any over-the-counter medications (e.g. aspirin, vitamins)? . ... Yes No N/A
11. Please provide any comments about your child’s visit with RANK PROVIDER NAME that you would like to share.
Please do not provide any personally identifiable information.
12. If you made an appointment for this visit, how did you make this appointment?
Phone 12a. When making this appointment, were you at any time told no appointments were available but to call back when they would be available? .................. Yes No
Patient Portal (TRICARE Online, MHS
Genesis Patient Portal) In Person
No, did not make appointment (ER, walk-in, someone else made appointment for me, etc.)
Please use pen or dark pencil to mark an “X” in the answer box:
Example: Correct Incorrect
LICENSE TO ADMINISTER: Report
RCS: DD-HA (D) 2598
Expires: June 30, 2025
For questions 13 through 15, please rate the following aspects of your child’s appointment:
13. How did your child receive care during this visit?
In person Via video visit Via telephone (audio only) Via email/secure messaging
N/A Poor Fair Good Very Good Excellent
14. If seen past your scheduled appointment time, the effort made to keep you informed about the delay. ..
15. Did your healthcare team begin to address your child’s needs within 30 minutes of your appointment time?
Yes No N/A
For questions 16 and 17, please rate the following aspects of your child’s care and service during THIS visit:
N/A Poor Fair Good Very Good Excellent
16. The courtesy and respectfulness of clerks and receptionists
17. The helpfulness of clerks and receptionists If your child also went to the Pharmacy, Laboratory, or Radiology Department in conjunction with THIS visit, please rate your experience with these services:
N/A Poor Fair Good Very Good Excellent
18. Overall experience with Pharmacy
19. Overall experience with Radiology
20. Overall experience with Laboratory
Please indicate how much you agree or disagree with the following statements:
Strongly
Disagree
Somewhat
Disagree
Neither
Agree nor
Disagree
Somewhat
Agree
Strongly
Agree
21. Overall, I am satisfied with the healthcare my child received on this visit
22. I would recommend this facility to a TRICARE-eligible family member or friend ........................................................................... …
23. In general, I am able to see my child’s provider when needed About you:
Poor Fair Good Very Good Excellent
24. In general, how would you rate your child’s overall health?
25.
In general, how would you rate your child’s overall mental or emotional health?
26. Please provide any comments about FACILITY NAME that you would like to share. Please do not provide any personally identifiable information.
Thank you very much for your opinions. Please return your questionnaire in the envelope provided to:
ATTN: MILITARY HEALTH SYSTEM SURVEY CENTER, c/o Ipsos, P.O. BOX 5030, CHICAGO, IL 60680-9858
Privacy Advisory: Your contact information was used to ask for your participation in this survey about your recent visit. Your responses are voluntary and your decision to participate or not will not affect your opportunity to receive future medical benefits. However, your responses to this survey about your recent experience in our treatment facility will allow us to maintain or improve the quality of the patient care provided to all receiving treatment at your facility. Please note, if during this survey you indicate a direct threat to harm yourself or others, we are required to forward information about that threat to appropriate authorities for action, which will likely include their contacting you.
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