Southern Jersey Family Medical Centers Would Like Your Feedback!

SECTION I: CONTEXT/DEMOGRAPHICS

Please take a few minutes to give your feedback about Southern Jersey Family Medical Centers, Inc. We would like to know how you feel about the services we provide, so that we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.

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* 1. What is your age?

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* 2. What is your gender identity?

1. Male

2. Female

3. Non-binary

4. Transgender Male

5. Transgender Female

6. Prefer not to say

Other (please specify)

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* 3. What is your Race/Ethnicity? (Check all that apply)

1. White/Caucasian

2. Black/African American

3. Hispanic/Latino

4. Asian

5. Native American/Alaskan Native

6. Native Hawaiian/Pacific Islander

7. Middle Eastern/North African

8. Multiracial/Multiethnic

9. Prefer not to say

Other (please specify)

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* 4. Do you have any of the following conditions? (Check all that apply)

1. Diabetes

2. Hypertension

3. COPD

4. Heart disease

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* 5. What is your name? (Optional)

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* 6. What health center do you visit most?

1. Salem

2. Merle Pavilion

3. Hammonton

4. English Creek

5. Buttonwood

6. Burlington

7. Women & Children (AC-2)

8. Atlantic City

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* 7. What is the name of the provider you saw? (ex, John Smith-Physician, John Smith-Dentist, John Smith- Nurse Practitioner, John Smith- Behavioral Health)

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* 8. How was your visit conducted?

1. Video

2. In the health center

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* 9. What type of appointment did you have?

1. Routine appointment

2. Sick appointment

3. Same day appointment

4. Walk-in

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* 10. How long have you been visiting us for your health care?

1. Less than six months

2. Between six months and a year

3. Between one and three years

4. Between three and five years

5. Longer than five years

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* 11. Do you have a patient portal account to access your medical visit notes and test results?

1. Yes

2. No

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* 12. Were you introduced to or invited to sign up for the patient portal?

Yes

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* 13. Would you like to sign up for the patient portal so that you can talk to your provider, get test results and schedule appointments on a phone or computer?

Yes

If you answered Yes, please provide your email and phone number

14% of survey complete.