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Surveyor Feedback Questionnaire on the State & Federal Regulatory Survey Process

This questionnaire includes 3 open-needed questions and 5 scale response questions.

To answer the scale response questions, please read each statement and select the response that best matches your opinion. Your choices range from:

1= Strongly Disagree......6= Strongly Agree

It will take you approximately 5 minutes to complete the questionnaire.
1.At the onset of the survey, provider representatives were available and responsive to discuss the purpose of the visit and to conduct the observational tour.
1 Strongly Disagree
2
3
4
5
6 Strongly Agree
Please rate your level of agreement.
2.The communications from the provider were clear and complete. This means that the provider was able to answer your questions about the processes being reviewed and responded to your requests for documentation in a timely manner.
1 Strongly Disagree
2
3
4
5
6 Strongly Agree
Please rate your level of agreement.
3.Access to the electronic medical record was easily obtained and did not hinder the survey process.
1 Strongly Disagree
2
3
4
5
6 Strongly Agree
Please rate your level of agreement.
4.Rate the tone/tenor of the survey visit.
1 Strongly Disagree
2
3
4
5
6 Strongly Agree
Respectful
Collaborative
5.The exit meeting was productive. This means that the appropriate people attended, there was ample time to ask questions and receive answers, and a general indication about the areas of concern were discussed.
1 Strongly Disagree
2
3
4
5
6 Strongly Agree
Please rate your level of agreement.
Please provide your feedback to the following questions.
6.What would make the survey process more constructive and productive? What can be improved?
7.Did you experience any barriers to making a compliance determination during the survey? If so, please describe.
8.What worked well during the regulatory survey? What were the highlights?
Thank you for completing this questionnaire.