fd-866.pdf

FD-866

Revised

2-11-2011

FEDERAL BUREAU OF INVESTIGATION

PATIENT QUALITY ASSURANCE QUESTIONNAIRE FOR VENDOR

PERFORMANCE

Date of FFD Exam: ______________________________ FIELD OFFICE/RA: _____________________________________________________

Clinic or location: __________________________________________________ Please comment and include contact information on form for any rankings of Fair or Poor

A. Please respond to the following statements regarding your FFD experience Excellent Good Fair Poor N/A

1. The Receptionist was courteous.

2. The waiting area was clean.

3. The wait time was < 5 min 5 - 15 15 - 30 30 +

3. There was suitable storage space for my personal belongings.

4. There was suitable storage space for my weapon.

5. The screening tests met my expectations.

6. The staff conducting the screening tests were knowledgeable/skilled with equipment use.

7. The examining physician discussed my medical history, including alcohol use, medications, allergies, operations, accidents, and hospitalizations.

8. The examining physician was courteous, professional and knowledgeable.

9. The examining physician discussed the results of my lab work and screening tests.

10. The physical examination met my expectations.

11. The examination had a logical flow from start to finish.

12. The examination room was clean and well lit.

13. All screening tests and procedures were conducted in one examination room..

14. My overall rating of my FFD exam experience was

B. STRESS TEST

15. It took ______ minutes to get from the vendor to the stress test facility 5 - 10 min 10 - 20 20 -30 30 + N/A

16. The directions provided regarding clothing and shoes for the stress test were adequate.

17. The stress test provider discussed the results of the stress test.

18. There was appropriate space for storage of my personal belongings and weapon.

19. The physician/staff performing the stress test was courteous, professional and knowledgeable.

20. My overall rating of the Stress Test experience was

Comment? (Please comment if rating is fair or poor)

Do you want your division nurse or your regional nurse to contact you? Yes No

Name and Telephone Number (Please include if you want a nurse to contact you) _________________________________________________________________ Please return completed form to your Fitness for Duty Coordinator Or Division nurse; who will forward to your Regional Occupational Health Nurse.

Please submit to your Division FFD Coordinator within 5 days of the completion of your FFD exam.