SHWC Feedback Form

The Student Health & Wellness Center (SHWC) is committed to providing the best care and services. In order to achieve this, we ask if you can complete this feedback form or kindly leave us a comment about your experience with our services.

Thank you for your time and valuable input.

Full Name

First (Given) Last (Family)

Student U# or N/A

Email Address

Confirmation Email

Cell/Mobile #

Date of Occurrence (if applicable)

Date

To better assist you, please indicate the contact method or location that prompted you to share your experience/feedback.

Let us know if you are completing this form to share

Other

Please indicate area of occurrence

Other

Select the clinical department where the occurrence transpired

Please select the Non-clinical department where the occurrence transpired

Other

For the following questions, please indicate on a scale of 1 to 5 with 5 being the best option and 1 being the worse

Was the SHWC staff member that assisted you knowledgeable?

	1	2	3	4	5

1 is Very Unfamiliar, 5 is Very Familiar

Was the SHWC staff member that assisted you Professional and Courteous?

	1	2	3	4	5

1 is Strongly Disagree, 5 is Strongly Agree

Based on your recent interaction with the SHWC staff member that assisted you, how satisfied or dissatisfied were you?

	1	2	3	4	5

1 is Very Dissatisfied, 5 is Very Satisfied

Were we able to satisfactorily meet your needs in a friendly, courteous, and respectful manner.

	1	2	3	4	5

1 is Very Dissatisfied, 5 is Very Satisfied

Did you receive information during the visit that you will use to improve your health? If yes, please explain

For the following Scheduling and Appointment questions, please indicate on a scale of 1 to 5 with 5 being the best option and 1 being the worse

Please indicate your satisfaction with the ease of scheduling an appointment?

	1	2	3	4	5

1 is Very Dissatisfied, 5 is Very Satisfied

Provide feedback if you selected a rating below a 3 for ease of scheduling an appointment, otherwise indicate N/A?

Did you experience any delay in the Check-In process at the KIOSK?

Please indicate your satisfaction with the efficiency of the check-in and check-out process

	1	2	3	4	5

1 is Very Dissatisfied, 5 is Very Satisfied

Did you have any concerns with duration of wait times during your interaction/visit?

Area:

Duration of wait:

For the following Visit related questions, please indicate on a scale of 1 to 5 with 5 being the best option and 1 being the worse

Were you satisfied with your interaction with the Clinical Staff (Nurse-Provider)?

How clear were the directives given to you by your provider?

	1	2	3	4	5

1 is Unclear, 5 is Very Clear

Please rate your overall experience.

	1	2	3	4	5

1 is Very Dissatisfied, 5 is Very Satisfied

If you were satisfied /dissatisfied with your visit please and would like to leave a brief summary of your experience, please indicate below

For the following Facility questions, please indicate on a scale of 1 to 5 with 5 being the best option and 1 being the worse

Was the temperature level comfortable in our facility during your visit

	1	2	3	4	5

1 is Very Uncomfortable, 5 is Very Comfortable

How satisfied are you with the cleanliness and appearance of our facility?

	1	2	3	4	5

1 is Very Unsatisfied, 5 is Very Satisfied

Based on your complete experience with our medical care facility, how likely are you to recommend us to a friend, colleague or classmate?

How could we improve our Services?

If you can change anything about our services, what would it be and why?

Your feedback is much appreciated

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Please rate your overall experience?

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