Health Center Evaluation Form
The members of the Health Care Advisory Committee ask that you help us evaluate the Colby Health Center by taking a few minutes to complete this form. If you would like to make additional comments or follow up on a specific complaint, we encourage you to contact Prof. Jan Holly Co-Chairperson of the Health Care Advisory Committee.

Instrutions:
Pace the mouse pointer on the small rectangle for pop-up menu to answer questions, A= Strongly agree, B= Agree, C= No opinion, D= Disagree, E= Strongly disagree .
Next , click in the comment box and type your responce.

THIS FORM WILL BE SENT ANONYMOUSLY VIA E-MAIL TO PROF. JAN HOLLY. WHEN YOU HAVE FINISHED JUST CLICK ON THE (SEND) BUTTON.

I received prompt and courteous assistance upon check in and when making appointments.

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I was seen in a timely fashion.

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I felt comfortable with my provider.

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I felt that my provider seemed to know what s/he was doing.

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I understood my diagnosis and treatment.

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My concerns were validated and my questions answered.

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My visit was treated confidentially and my privacy respected.

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I recieved satisfactory follow-up care, if applicable.

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Overall grade of the experience at the Health Center

Comments

Would you return to the Health Center with a future problem?. YES / NO

Would you recommend the Health Center to a friend YES / NO?

Was your provider a NURSE, NURSE PRACTITIONER, MD, PA, TRAINER?

Optional information:

Class Year: Gender: Male Female

Were you a/an Inpatient, Office appointment, or a walk-in?.

THIS FORM WILL BE SENT ANONYMOUSLY VIA E-MAIL TO PRO. JAN HOLLY CO-CHAIR OF THE HEALTH CARE ADVISORY COMMITTEE WHEN YOU HAVE FINISHED JUST CLICK ON THE (SEND ) BUTTON OR IF YOU PREFER YOU MAY PRESS "LOAD" AND A COPY WILL BE DOWNLOADED AS A WORD DOCUMENT AND CAN BE PRINTED. THEN YOU MAY FILL OUT THE FORM AND SEND THE EVALUATION BY CAMPUS MAIL.

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Thank You

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