Patient Survey

1. Patient Survey Please take a moment to complete our Patient Survey. All clinic patients will be surveyed after each scheduled follow-up appointment. Your opinions are important to us! We strive to provide the best care possible to all of our patients. Only our patients can let us know how we are doing! This survey is confidential. Place in the designated reply box when you have completed or return to us in the provided envelope. The replies will be handled and tabulated by non-clinical staff and will, in no way, affect your treatment or care. Date of clinic visit:__________________ Please rate your over-all clinic experience TODAY by circling the number: Poor Fair OK Good Excellent 1--------------2----------------3--------------4----------------5 Please indicate any specific problems you had today with the clinic, the facility, or staff: Were all your questions answered to your satisfaction? ( ) Yes ( ) No Other Comments:

3. University of Nebraska Medical Center HIV Program Quality Management Program Quality Committee Performance Improvement Plan Report Start Date:_____________________ November 1, 2002 Report submitted by:___________________________________Date:______________ July 2003