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  1. Surveys
  2. 2005
  3. April
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  5. Sample Survey
 
 
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.
 
 
 
Additional Comments/Suggestions for improvement
   
 
 
The next section refers to the hospital where you admit the most patients.
Strongly agree Somewhat agree Neutral Somewhat disagree Strongly disagree No opinion
Administration listens to physician concerns
Administration listens to physician concerns, but responds to the wrong physician groups
I have a good professional relationship with administration
During the last year my professional relationship with administration has improved
 
 
Professional referrals may be made based on a number of factors. For each of the following items, please indicate the extent to which you think each is important in selecting a hospital for your patients.
Very Important Important Not too Important Not at all Important No Opinion
The price of hospital services
Your satisfaction with the medical staff
The reputation of the hospital
The reputation of hospital based physicians
The reputation of specialists practicing at the hospital
Communication between you and the consulting physician
Competence of nursing staff
Past experiences of patients
Economic condition of the patient
Convenience of hospital for patient and family
Patient hospital preference
Religious preference
The likelihood of them referring your patients to you
 
 
 
Please indicate the composition of your patient load by revenue sponsorship:
% Medicaid
% Medicare
% Self Pay
% Private Insurance
% HMO
% Other
0
 
 
 
Thank you for taking the time to respond.
 
 
 
Dear Customer:



As the manager of [COMPANY], I want to thank you for giving us the opportunity to serve you. Please help us serve you better by taking a couple of minutes to tell us about the service that you have received so far. We appreciate your business and want to make sure we meet your expectations. Attached, you will find a coupon good for ...... We hope that you will accept this as a token of our good will.



Sincerely,

[MANAGER_NAME]

Manager
 
 
 
In your most recent customer service experience, how did you contact the representative?

 
In Person
 
By Telephone
 
Internet
 
Through a Dealer/Retailer/Broker
 
Other
 
 
 
 
About how long did you have to wait before speaking to a representative?
 
I was taken care of immediately
 
Within 3 minutes
 
3-5 minutes
 
5-10 minutes
 
More than 10 minutes
 
 
 
Did our representative... (Select all that apply)



 
Quickly identify the problem
 
Appear knowledgeable and competent
 
Help you understand the cause and the solution to the problem
 
Handle issues with courtesy and professionalism

 
 
 
About how long did it take to get this problem resolved?
 
Immediate Resolution
 
Less than a day
 
Between 2 and 3 days
 
Between 3 and 5 days
 
More than a week
 
The problem is still not resolved
 
 
 
How many times did you have to contact customer service before the problem was corrected?
 
Once
 
Twice
 
Three Times
 
More than Three times
 
 

Very Satisfied Somewhat Satisfied Neutral Somewhat Dissatisfied Very Dissatisfied
Overall, how satisfied are you with the customer service experience?
 
 
How satisfied are you with your service from [COMPANY]?
 
Extremely satisfied
 
Very satisfied
 
Neutral
 
Very dissatisfied
 
Extremely dissatisfied
 
 
 
How satisfied are you with your service from [COMPANY]?
 
Extremely satisfied
 
Very satisfied
 
Neutral
 
Very dissatisfied
 
Extremely dissatisfied
 
Physicians Business Network
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