HTF 402 National First Nations Telehealth Research Project
 (47
K)
Attachment 4: Satisfaction Questionnaire
TELEHEALTH SATISFACTION SURVEY (FOR TELEREHABILITATION AND TELEVISITATION
SESSIONS) FAX TO : 514-398-1531
Speech/language therapy - Occupational therapy - Physical therapy
- Televisitation
Patient code, Gender (Male/Female), Age (0 - 20 / 21 - 40 / 41
- 60 / 61 - 80 /80+)
- How satisfied were you with:
- The voice quality of the equipment? (Poor / Fair / Good
/ Excellent)
- The visual quality of the equipment? (Poor / Fair / Good
/ Excellent)
- Your personal comfort in using the telehealth system?
(Poor / Fair / Good / Excellent)
- The length of time to get an appointment in Fort Chip?
(Poor / Fair / Good / Excellent)
- The ease of getting to the telehealth department (circle
one: taxi, private, walked, CHR, staff) (Poor / Fair / Good
/ Excellent)
- The length of time with the therapist or family member
you saw? (Poor / Fair / Good / Excellent)
- The explanation of your treatment by the telehealth staff?
(Poor / Fair / Good / Excellent)
- The thoroughness, carefulness and skillfulness of the
telehealth staff? (Poor / Fair / Good / Excellent)
- The courtesy, respect, sensitivity and friendliness of
the telehealth staff? (Poor / Fair / Good / Excellent)
- How well the telehealth staff respected your privacy?
(Poor / Fair / Good / Excellent)
- How well the staff answered your questions about the equipment?
(Poor / Fair / Good / Excellent)
- Your overall treatment experience at using telehealth?
(Poor / Fair / Good / Excellent)
- Would you use Telehealth again? (No / Yes)
- Would you recommend telehealth to another person? (No
/ Yes)
- Comments
- Self-administered - With help By
- PLEASE FAX THE COMPLETED FORMS TO: 514-398-1531. IF
YOU HAVE ANY QUESTIONS OR COMMENTS PLEASE CALL 514-398-3247.
Based on a form developed by the Saskatchewan Northern Telehealth
Network.
PATIENT SATISFACTION SURVEY (USE FOR PATIENT CARE SESSIONS) FAX
TO : 514-398-1531
Patient code, Gender (Male/Female), Age (0 - 20 / 21 - 40 / 41
- 60 / 61 - 80 /80+)
- How satisfied were you with:
- Your general health? (Poor / Fair / Good / Excellent)
- The length of time to get an appointment with Telehealth?
(Poor / Fair / Good / Excellent)
- The length of time waiting in the office at Telehealth?
(Poor / Fair / Good / Excellent)
- The length of time with the specialist you saw? (Poor
/ Fair / Good / Excellent)
- The explanation of your condition by the specialist? (Poor
/ Fair / Good / Excellent)
- The explanation of your treatment by the specialist? (Poor
/ Fair / Good / Excellent)
- The thoroughness, carefulness and skillfulness of the
specialist you saw? (Poor / Fair / Good / Excellent)
- The courtesy, respect, sensitivity and friendliness of
the specialist you saw? (Poor / Fair / Good / Excellent)
- How well the staff here respected your privacy? (Poor
/ Fair / Good / Excellent)
- How well the staff here answered your questions about
the equipment? (Poor / Fair / Good / Excellent)
- How well the staff here treated you with respect? (Poor
/ Fair / Good / Excellent)
- Your overall treatment experience at Telehealth? (Poor
/ Fair / Good / Excellent)
- Did you have any difficulties getting here today? (No/Yes)
- Would you use Telehealth again? (No/Yes)
- Would you recommend telehealth to another person? (No/Yes)
- Any other comments about telehealth?
- Self-administered / With help / Orally By
PLEASE FAX THE COMPLETED FORMS TO: 514-398-1531. IF YOU HAVE
ANY QUESTIONS OR COMMENTS PLEASE CALL 514-398-3247.
Used by permission of the Saskatchewan Northern Telehealth Network.
PATIENT SATISFACTION SURVEY (LA ROMAINE TELEHEALTH SESSIONS)
FAX TO: 514-398-1531
Patient code, Date
- Were you satisfied with:
- Your general health?
(Poor/Fair/Good Excellent)
- The waiting time for use of the telehealth equipment? (Poor/Fair/Good Excellent)
- he waiting time to receive the results of the telehealth session? (Poor/Fair/Good Excellent)
- How well the staff respected your privacy? (Poor/Fair/Good Excellent)
- How well the staff answered your questions about the equipment? (Poor/Fair/Good Excellent)
- How well the staff treated you with respect? (Poor/Fair/Good Excellent)
- Your telehealth experience in general? (Poor/Fair/Good Excellent)
- Did you find it difficult to get here today? (No/Yes)
- Is this the first time you have used the telehealth service? (No/Yes)
- Would you use telehealth again? (No/Yes)
- Would you choose telehealth over a visit to the doctor? (No/Yes)
- Would you recommend telehealth? (No/Yes)
- Any other comments you may wish to make about telehealth?
- Self-administered / With help / Orally by
- PLEASE FAX THE COMPLETED FORMS TO 514-398-1531.
IF YOU HAVE ANY QUESTIONS OR COMMENTS, PLEASE CALL 514-398-3247.
Adapted and used with the permission of the Saskatchewan Northern Telehealth Network
PATIENT SATISFACTION SURVEY (USE FOR PATIENT CARE SESSIONS) FAX
TO : 514-398-1531
Patient code, Gender (Male/Female), Age (0 - 20 / 21 - 40 / 41
- 60 / 61 - 80 /80+)
- How satisfied were you with:
- Your general health?
- The length of time to get an appointment with Telehealth?
(Poor / Fair / Good / Excellent)
- The ease of getting to the Telehealth site? (Poor / Fair
/ Good / Excellent)
- The length of time waiting in the office at Telehealth?
(Poor / Fair / Good / Excellent)
- The length of time with the specialist you saw? (Poor
/ Fair / Good / Excellent)
- The explanation of your condition by the specialist? (Poor
/ Fair / Good / Excellent)
- The explanation of your treatment by the specialist? (Poor
/ Fair / Good / Excellent)
- The thoroughness, carefulness and skillfulness of the
specialist you saw? (Poor / Fair / Good / Excellent)
- The courtesy, respect, sensitivity and friendliness of
the specialist you saw? (Poor / Fair / Good / Excellent)
- How well the staff here respected your privacy? (Poor
/ Fair / Good / Excellent)
- How well the staff here answered your questions about
the equipment? (Poor / Fair / Good / Excellent)
- How well the staff here treated you with respect? (Poor
/ Fair / Good / Excellent)
- Your overall treatment experience at Telehealth? (Poor
/ Fair / Good / Excellent)
- To use the telehealth service today, did you have to
- Arrange child care? (No/Yes) , Cost to you:
- Pay for any costs? (No/Yes), About how much (not child
cost)
- Would you use Telehealth again? (No/Yes)
- Would you recommend telehealth to another person? (No/Yes)
- Any other comments about telehealth?
- Self-administered / With help / Orally By:
- PLEASE FAX THE COMPLETED FORMS TO: 514-398-1531. IF
YOU HAVE ANY QUESTIONS OR COMMENTS PLEASE CALL 514-398-3247.
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