Outpatients Satisfaction Survey

Facility *

Department

Date

Are you satisfied with the length of time you had to wait for your appointment?

Yes, definitely

Yes, to some extent

No

Were you able to choose an appointment time (day/hour) that fit your schedule?

Yes, definitely

Yes, to some extent

No

The day of your appointment, how long did you have to wait before being registered?

I did not have to wait

Less than 15 minutes

16-30 mins

31-60 mins

More than 1 hour

Not applicable

How long after the scheduled appointment time did your appointment start?

See on time, or earlier

Waited less than 15 mins

Waited 15-30 mins

Waited 31-60 mins

Waited more than 1 hour

Did the staff treat you with courtesy and respect?

Yes, definitely

Yes, to some extent

No

Did the staff introduce themselves, by stating their name and role, before providing care or treatments?

Yes, always

Yes, sometimes

Never

Was your privacy respected by staff during care or treatments (e.g. closed the door, pulled the curtain)?

Yes, definitely

Yes, to some extent

No

During your appointment/treatment, did the staff explain things in a way you could understand?

Yes, definitely

Yes, to some extent

No

I didn’t need any explanations / Not applicable

Were you involved as much as you wanted to be in decisions about your care/treatments?

Yes, definitely

Yes, to some extent

No

I wasn’t well enough to be involved

Did you receive help from the staff, if needed?

Yes, always

Yes, sometimes

No

A staff member was with me all the time

I didn’t need any help / Not applicable

In your opinion, how clean were the rooms?

Very clean

Fairly clean

Not very clean

Not clean at all

Did you notice if staff washed or disinfected their hands before caring for you?

Yes, always

Yes, sometimes

Never

I didn’t notice

I didn’t see any facilities for washing/disinfecting hands

Did staff check your identity (e.g. name, date of birth, bracelet) before giving you medication or treatments?

Yes, always

Yes, sometimes

No

I don't remember

Before giving you a medication, did the staff tell you what it was for?

Yes, always

Yes, sometimes

Never

I wasn’t given any medication / Not applicable

Before leaving, did the staff explain the reason for, and possible side effects of, newly prescribed medications?

Yes, definitely

Yes, to some extent

No

I wasn’t prescribed any new medication / Not applicable

Did a staff member talk to you about things to watch for regarding your illness or treatment after you went home?

Yes, completely

Yes, to some extent

No

No, I didn’t need this information / Not applicable

Was the written information you received about your health problem or treatment easy to understand?

Yes, definitely

Yes, to some extent

No

did not receive information but I would have liked some

Not applicable

Did a staff member tell you who to call if you had questions about your health problem or your treatment after you went home?

Yes

No

Not applicable

How often did you receive the service you needed in the official language (English or French) of your choice?

Always

Usually

Sometimes

Never

Overall, how was your experience during this visit? 0 is the worst experience and 10 is the best experience

Comments

Optional

Name

Telephone