Name: Address:
Gender: Age:
Contact info:
Catergory: Patient (in/out), Doctor (Resident/Senior), Visitor(First time/Regular),
Nurse(Senior/Junior), Supporting Staff(Maintainence/Cleaning/Misc.), Hosp. Adm.
(CMO/Manager/Others), Attendant (Shifting/Non-shifting)
GENERAL
1. How would you rate the overall administration of the hospital?
1 2 3 4 5
2. Rate your experience with the hospital in general
12 3 4 5
3. How clean do you find the hospital?
1 2 3 4 5
[Link] satisfied are you with the communication among the staff?
1 2 3 4 5
[Link] likely are you to recommend this hospital to someone visiting for the first
time?
1 2 3 4 5
NURSES
[Link] you feel that the staff roles and responsibilities are clearly defined?
1 2 3 4 5
[Link] you think the staff needs some additional trainings or resources?
1 2 3 4 5
[Link] you feel supported by the hospital administration in your role?
1 2 3 4 5
4. Are you satisfied with your working hours?
1 2 3 4 5
PATIENT CARE
[Link] would you rate the hospital’s commitment to patient care?
1 2 3 4 5
[Link] effectively does the administration/concerned authorities respond to
patient feedback?
1 2 3 4 5
[Link] would you rate the thoroughness of your medical examination?
1 2 3 4 5
4. How easy was it for you to schedule your appointment?
1 2 3 4 5
ADMINISTRATION
[Link] far do you agree that the hospital has the best policies in place for
handling emergencies and disaster management?
1 2 3 4 5
[Link] far do you agress that the hospital has financial aid programs available for
low-income and/or underpriveledged patients?
1 2 3 4 5
[Link] much do you agree that the telemedicine or the remote consultation
services are integrated into the hospital’s workflow?
1 2 3 4 5
[Link] efficiently does the administration allocate resources across departments?
1 2 3 4 5
DOCTORS
[Link] would you rate your workload and its impact on patient care?
1 2 3 4 5
[Link] satisfied are you with the resources available to support your practice?
1 2 3 4 5
[Link] likely are you to recommend working in this hospital to fellow
doctors/associates?
1 2 3 4 5
[Link] would you rate the collaboration between healthcare team members?
1 2 3 4 5
VISITORS/ATTENDING
[Link] satisfied are you with the communication from healthcare providers about
your loved one’s condition?
1 2 3 4 5
[Link] would you rate the comfort of waiting area and other facilities for visitors ?
1 2 3 4 5
[Link] well do you think your concerns/questions are addressed by the staff?
1 2 3 4 5
[Link] well do you think the hospital makes policies for the visitors/attendants?
1 2 3 4 5
OVERALL
1. How transparent do you find the hospital’s financial practices?
1 2 3 4 5
[Link] likely are you to return to this hospital for future care ?
1 2 3 4 5
4How would you rate the availability of parking lot and other associated facilities
of the hospital?
1 2 3 4 5
[Link] there anything that you think the hospital needs to work on to be even more
efficient in providing healthcare facilities?
[Link] suggestions for the administration/staff of the hospital?
