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*

A positive/satisfactory experienceConcernGeneral feedbackOther

Please indicate area of occurrence*

Clinical (medical treatment, etc.)Non-Clinical (customer service/scheduling, etc.)FacilityOther

Select the clinical department where the occurrence transpired*

Please select the Non-clinical department where the occurrence transpired*

Patient BillingPatient Services (Call Center/Check-in Desk)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?*

YesNo

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?*

YesNo

Area:*

Duration of wait:*

Over 10 minutes but less than 20 minutesOver 20 minutes but less than 30 minutesOver 30 minutes

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)?*

YesNo

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?*

LikelyNot Likely

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 *

Free Text Above

Preferred method of communication*

EmailPhone Call

Please rate your overall experience?*

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