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19
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HIPAA
Compliance
1
Name
(Field is not required)
First Name
Last Name
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2
Date
*
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Date
Year
Month
Day
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3
State
*
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Please Select
NC
VA
SC
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Please Select
NC
VA
SC
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4
Office Location
*
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5
OM Email Address
*
This field is required.
enter your office manager's email address
example@example.com
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6
Regional Manager
*
This field is required.
Please Select
Kristy Daniel
Megan Holiday
Robin Pestano
Alison Sarafino
Jason Niebauer
Beverly Hudson
Coast
Virginia
TRC
RCM
Please Select
Please Select
Kristy Daniel
Megan Holiday
Robin Pestano
Alison Sarafino
Jason Niebauer
Beverly Hudson
Coast
Virginia
TRC
RCM
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7
Job position
*
This field is required.
Please Select
Dentist
Office Manager/AOM
RDH
Dental Assistant (General, Ortho, Specialty)
Hygiene Assistant
Sterilization Tech
Patient Coordinator
Scheduling Coordinator/Treatment Coordinator
RCM (Insurance/Collections Coordinator/Credentialing)
Support Center
Please Select
Please Select
Dentist
Office Manager/AOM
RDH
Dental Assistant (General, Ortho, Specialty)
Hygiene Assistant
Sterilization Tech
Patient Coordinator
Scheduling Coordinator/Treatment Coordinator
RCM (Insurance/Collections Coordinator/Credentialing)
Support Center
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8
Please answer the following questions
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I understand what is expected of me in doing my job.
Row 0, Column 0
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Communication from management is clear and effective.
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I get the support I need from my manager.
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I feel that I am a part of a goal-oriented team.
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We work well together on my team.
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There is open and honest two-way communication on my team.
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I have the tools / equipment / technology I need to be most effective in my role.
Row 6, Column 0
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I am happy with the recognition I've received in this organization to date.
Row 7, Column 0
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I would recommend this company to family or friends as a great place to work.
Row 8, Column 0
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Row 8, Column 4
I understand what is expected of me in doing my job.
Communication from management is clear and effective.
I get the support I need from my manager.
I feel that I am a part of a goal-oriented team.
We work well together on my team.
There is open and honest two-way communication on my team.
I have the tools / equipment / technology I need to be most effective in my role.
I am happy with the recognition I've received in this organization to date.
I would recommend this company to family or friends as a great place to work.
Strongly Disagree
Row 0, Column 0
Disagree
Row 0, Column 1
Neutral
Row 0, Column 2
Agree
Row 0, Column 3
Strongly Agree
Row 0, Column 4
Strongly Disagree
Row 1, Column 0
Disagree
Row 1, Column 1
Neutral
Row 1, Column 2
Agree
Row 1, Column 3
Strongly Agree
Row 1, Column 4
Strongly Disagree
Row 2, Column 0
Disagree
Row 2, Column 1
Neutral
Row 2, Column 2
Agree
Row 2, Column 3
Strongly Agree
Row 2, Column 4
Strongly Disagree
Row 3, Column 0
Disagree
Row 3, Column 1
Neutral
Row 3, Column 2
Agree
Row 3, Column 3
Strongly Agree
Row 3, Column 4
Strongly Disagree
Row 4, Column 0
Disagree
Row 4, Column 1
Neutral
Row 4, Column 2
Agree
Row 4, Column 3
Strongly Agree
Row 4, Column 4
Strongly Disagree
Row 5, Column 0
Disagree
Row 5, Column 1
Neutral
Row 5, Column 2
Agree
Row 5, Column 3
Strongly Agree
Row 5, Column 4
Strongly Disagree
Row 6, Column 0
Disagree
Row 6, Column 1
Neutral
Row 6, Column 2
Agree
Row 6, Column 3
Strongly Agree
Row 6, Column 4
Strongly Disagree
Row 7, Column 0
Disagree
Row 7, Column 1
Neutral
Row 7, Column 2
Agree
Row 7, Column 3
Strongly Agree
Row 7, Column 4
Strongly Disagree
Row 8, Column 0
Disagree
Row 8, Column 1
Neutral
Row 8, Column 2
Agree
Row 8, Column 3
Strongly Agree
Row 8, Column 4
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9
Please rate your satisfaction with your position
1
2
3
4
5
Extremely Dissatisfied
Extremely Satisfied
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10
Please rate your satisfaction with the Company
1
2
3
4
5
Extremely Dissatisfied
Extremely Satisfied
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11
Please rate your satisfaction with your Department/Office location
1
2
3
4
5
Extremely Dissatisfied
Extremely Satisfied
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12
Please rate our core values: Teamwork
Are we focusing on group success; communicating well; meeting your commitments; lifting up our team
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2
3
4
5
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13
Please rate our core values: Integrity
Are we being honest; being ethical; keeping our word; accepting responsibility
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3
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5
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14
Please rate our core values: Compassion
Are we being empathetic; being patient; being kind; providing outstanding customer service to our peers and patients
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5
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15
Please rate our core values: Competence
Are we: using your talents; thinking critically; paying attention to details and having a 'yes, I can' attitude
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5
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16
Please rate our core values: Adaptability
Are we: being flexible, have a growth mindset; embracing change; welcoming feedback
1
2
3
4
5
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17
What is one thing you feel we can improve on?
*
This field is required.
Please Select
Company Culture
Benefit/Wages
Communication
General Office Issues
Management
No Issues Stated
Please Select
Please Select
Company Culture
Benefit/Wages
Communication
General Office Issues
Management
No Issues Stated
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18
Please share your additional feedback and comments on what we can do better
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19
Thank you!
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