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Hello:
You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be stricly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below.
Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
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| If available, would you use an online system to schedule an appointment? |
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| Would you visit the Health Center again (or for a first time)? |
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| Did you have confidence in the medical staff that you interacted with? |
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| Did you have trust in the medical staff that you interacted with? |
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| Before any treatment(s) did a member of the medical staff explain what would happen? |
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| Before any treatment(s) did a member of the medical staff explain any risks in a way you could understand? |
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Please check the type of care you received
in the Health Center during your last visit:
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Please rate your overall satisfaction with services that you have received from the Health Center:
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| How long did you have to wait to be seen? |
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| In your opinion, how clean was the Health Center? |
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| During your visit with whom did you interact? (check all that apply) |
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| If you had important questions during your visit at the Health Center, did you receive answers that you could understand? |
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| While you were in the Health Center, how much information or treatment was given to you? |
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| Were you involved as much as you wanted to be in decisions about your care and treatment? |
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| Which of the following best describes your current housing situation? |
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| How many times have you used the Health Center in the last year? |
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| If not, what was not provided that you thought you needed? | | |
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| Racial / Ethnic Categories (select one): |
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| Your age at the date of last birthday | | |
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| The Health Center provides many health and wellness services to the college community. Of these services, which ones are you aware of? (check all that apply) |
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| If the Health Center was to provide the following services (listed below) which would you use? |
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| The Health Center is committed to meeting the needs of the students. Please rank the following items in order of importance (1) to least important (5) that you consider when visiting the Health Center. |
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| Minimal waiting time for service. |
| | | Times that coordinate with my schedule. |
| | | Ability to speak with a doctor concerning my treatment. |
| | | Ability to speak with someone of my same gender regarding my treatment. |
| | | No cost / Low cost medication(s). |
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| Did you have confidence in the medical staff that you interacted with? |
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