This template is HCAHPS standards compliant.

1. Peppertree Family Medicine Center
Post-Visitation Personal Assessment
ASSESMENT INSTRUCTIONS
♦ We would like to receive a feedback from you about the appointment scheduling we provide.
♦ Please, help us to improve our process by completing this assessment.
♦ All responses will be kept confidential and anonymous.
♦ We would like to meet your needs for care.
.Answer all the questions by checking the box c)Were the phone menu instructions easy to
to the left of your answer. understand?
1.OUR PHONE SYSTEM
a)Was it easy to reach a live operator on the □ Strongly disagree
phone?
□ Strongly disagree □ Disagree
□ Disagree □ Neither agree nor disagree
□ Neither agree nor disagree □ Agree
□ Agree □ Strongly agree
□ Strongly agree d)Was it clear when to choose scheduler or
triage nurse?
b)Did you wait a long time to reach a live
operator? □ Strongly disagree
□ Strongly disagree □ Disagree
□ Disagree □ Neither agree nor disagree
□ Neither agree nor disagree □ Agree
□ Agree □ Strongly agree
□ Strongly agree
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2. Peppertree Family Medicine Center
2.TELEPHONE PERSONNEL d)Did the live operator answer all of your
questions?
□ Strongly disagree
a)Was the live operator friendly and helpful?
□ Strongly disagree
□ Disagree □ Disagree
□ Neither agree nor disagree □ Neither agree nor disagree
□ Agree □ Agree
□ Strongly agree □ Strongly agree
3.EASE OF GETTING AN APPOINTMENT
b) Did the live operator treat you with
courtesy and in professional manner? a)Was it easy to get an appointment?
□ Strongly disagree □ Strongly disagree
□ Disagree □ Disagree
□ Neither agree nor disagree □ Neither agree nor disagree
□ Agree □ Agree
□ Strongly agree □ Strongly agree
c) Did the live operator show concern and
b)An appointment was available when needed?
sensitivity to your needs?
□ Strongly disagree □ Strongly disagree
□ Disagree □ Disagree
□ Neither agree nor disagree □ Neither agree nor disagree
□ Agree □ Agree
□ Strongly agree □ Strongly agree
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3. Peppertree Family Medicine Center
c)An appointment with desired doctor was c)Did you feel that your privacy was protected?
available when needed?
□ Strongly disagree
□ Strongly disagree
□ Disagree
□ Disagree
□ Neither agree nor disagree
□ Neither agree nor disagree
□ Agree
□ Agree
□ Strongly agree
□ Strongly agree
4.REQUESTED INFORMATION
5. What do you like least about your scheduling
a)Did the live operator verify that your insurance experience?
is accepted from our office?
□ Strongly disagree
□ Disagree
□ Neither agree nor disagree
□ Agree
□ Strongly agree 6. Do you have any suggestions?
b)Did the live operator get your address
information?
□ Strongly disagree
□ Disagree
□ Neither agree nor disagree
□ Agree
□ Strongly agree
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4. Peppertree Family Medicine Center
7. ABOUT YOU
a) Your Age: ______
b) Your Sex: ______Male _______Female
c) What language do you speak:
English_____ Spanish_______
d) Are you new patient: ________Yes _______No
THANK YOU FOR COMPLETING OUR SURVEY!
WE VALUE YOUR OPINIION!
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