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* 1. Your Age

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* 2. Gender

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* 3. Nationality 

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* 4. Do you consider this center your regular source of care?

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* 5. When your given information from your provider and/or pharmacist how often do you need help understanding it?

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* 6. How are we doing in the following areas: Waiting/Safety? 5 Being Excellent and 1 being Low;  Skip if N/A

  5 being great 1 being poor
Time in waiting room
Time in exam room
Time for appointment
Safety while on campus

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* 7. How are we doing in the following Departments?  Skip if N/A

  5 Being Great 1 Being Poor
Outreach/ CHR
Transportation
Purchased and Referred are (PRC)
Ambulance/EMS

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* 8. Staff: Provider: (physician, Dentist, Physician Assistant, Nurse Practitioner, Behavior Health Counselors ;  Skip if N/A

  5 Being Great 1 Being Poor
Listens to you
Takes enough time with you
Explains what you want to know
Gives you good advice and treatment

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* 9. How was your Virtual appointment?  Skip if N/A

  5 Being Great 1 Being Poor
Connectivity 
Waiting Time
Scheduling of appointment
How likely are you to schedule another virtual appointment
Would you like to see more Virtual service options

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* 10. Laboratory and Radiology ;  Skip if N/A

  5 Being Great 1 Being Poor
Friendly and Helpful to you
Answers our questions

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* 11. Pharmacy;  Skip if N/A

  5 Being Great and 1 Being Poor
Friendly, helpful and answers your questions
Refill process meets your needs
Privacy of consultations 

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* 12. Facility

  5 Being Great 1 Being Poor
Neat and Clean Buildings
Comfort and Safety while on campus

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* 13. Confidentiality- Keeping my personal information private

1 5
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 14. Primary Care Medical Home (PCMH) , is a model of care where services are provided to patients by a primary care practitioner and team that increases access to its services, tracks and coordinated a patient’s care delivered by other practitioners and facilities, uses evidence based treatment protocols and focuses more on patient and family education and self management. A “Medical home” focuses on the relationship between the patient, his/her family, and the people that work at the healthcare clinic.

Do you know your Primary Care Medical Home Team: (Acorn / River Ducks) :

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* 15. If you marked Yes, has this improved your access to care, treatment, services, and communication?

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* 16. Your suggestions for improvement, including patient Safety?

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* 17. If you have any suggestions for the Kimaw.org website, please note them below.
Thank you for taking the time to complete this survey !

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