DePere Memorial Hospital would like you to take a few minutes to complete the following survey.
Please note you may "Enter Comments" at any time by using the field at the bottom of this form.
Exposure to DePere Memorial Hospital
Was this your first time as a patient at DePere Memorial Hospital?
Yes
No
Has one of your relatives or friends ever been a patient in this hospital?
Yes
No
How did you select DePere Memorial Hospital?
My doctor insisted
My doctor recommended
Doctor gave options
Personal selection by me
I insisted, doctor agreed
Insurance mandated hospital
Emergency brought me here
Other
What is the specialty of the doctor who admitted you to this hospital?
General/Family/Internal
Pediatrician
OB/GYN
Ear,Nose,Throat
General Surgery
Neurosugery
Urology
Orthopedic
Cancer/Tumor
Other
How many days were you in the hospital?
1 to 3 days
4 to 6 days
7 or more
What type of unit were you in for most of your stay?
Surgical
Maternity
General Medical
Intensive/Critical
Rehabilitation
Pediatric/Childrens
Other
DePere Memorial Hospital has the
Strongly Agree
|
Strongly Disagree
Highest quality doctor staff in the area...
+3
+2
+1
0
-1
-2
-3
Highest quality nursing staff in the area...
+3
+2
+1
0
-1
-2
-3
Most up-to-date medical equipment and facilities in the area...
+3
+2
+1
0
-1
-2
-3
DURING THE REGISTRATION PROCESS
Strongly Agree
|
Strongly Disagree
The person who handled my registration was polite and friendly...
+3
+2
+1
0
-1
-2
-3
Hospital Staff
Strongly Agree
|
Strongly Disagree
My doctors were skilled and experienced...
My doctor was kind and caring...
The nurses were skilled in the treatment they provided me...
The nurses were responsive when I called...
I was never unnecessarily awakened (by the staff) during the night...
Tests and procedures were completely explained to me...
How important are each of the following reasons why you chose DePere Memorial Hospital.
LOCATION?
Extremely Important
Very Important
Relatively Important
Somewhat Important
Not Important
Family/Friend's recommendation?
Extremely Important
Very Important
Relatively Important
Somewhat Important
Not Important
Past Experience?
Extremely Important
Very Important
Relatively Important
Somewhat Important
Not Important
Cost?
Extremely Important
Very Important
Relatively Important
Somewhat Important
Not Important
OPTIONAL BUT VERY IMPORTANT Will be kept strictly confidential. Please select your age group.
Less than 18
18 to 24
25 to 34
35 to 44
45 to 64
65 or older
OPTIONAL BUT VERY IMPORTANT Will be kept strictly confidential. Please indicate your gender.
Male
Female
Overall level of satisfaction with the medical care received at DePere Memorial Hospital
Expected Level of Service
Actual Level of Service
Excellent Medical Care
Excellent Medical Care
Very Good Medical Care
Very Good Medical Care
Satisfactory Medical Care
Satisfactory Medical Care
Poor Medical Care
Poor Medical Care
Unacceptable Care (explain)
Unacceptable Care (explain)
Please indicate if you chose DePere Memorial Hospital because of a specific service offered..
No
Yes (Specify Service)
If I were to describe my experience to the Administrator of DePere Memorial Hospital, I would say...
Additional Comments:
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