NEMSA STAFF HEALTH MAINTENANCE ORGANIZATION (HMO) FEEDBACK QUESTIONNAIRE Waiting time before seeing the doctor * Very Good Good Fair Poor Very Poor Ease of reaching Regenix * Very Good Good Fair Poor Very Poor Section A: General Information The doctor’s professionalism and attention * Very Good Good Fair Poor Very Poor Helpfulness of staff * Very Good Good Fair Poor Very Poor Friendliness of nurses and staff * Very Good Good Fair Poor Very Poor Response time * Very Good Good Fair Poor Very Poor Cleanliness of the facility * Very Good Good Fair Poor Very Poor 1. Name (optional) 1. Name (optional) First First Last Last Resolution of issues * Very Good Good Fair Poor Very Poor Access to prescribed medication * Very Good Good Fair Poor Very Poor Communication clarity * Very Good Good Fair Poor Very Poor 2. Department/Unit (optional) Laboratory/diagnostic services * Very Good Good Fair Poor Very Poor Attitude of staff * Very Good Good Fair Poor Very Poor Overall hospital experience * Very Good Good Fair Poor Very Poor 3. Gender * Male Female 4. Age Group * Under 25 25-34 35-44 45-54 55 and above Section B: Your Hospital/Clinic Experience 5. How often do you visit your NHIS Health Care Provider? * Once a month Once a quarter Once a year Whenever the need arises Not at all 6. How would you rate the following services at your hospital/clinic? * 7. Have you ever had to pay out of pocket for any service that should have been covered? * Yes No If yes, please specify: Section C: Regenix HMO Support 8. Have you ever contacted Regenix directly for support or clarification? * Yes No 9. If yes, how would you rate their customer service? * 10. Have you been denied medical attention due to attitude/response from Regenix? * Yes No Section D: Overall Satisfaction and Suggestions 11. Overall, how satisfied are you with Regenix services? * Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied 12. What has been your biggest challenge with Regenix or your hospital? 13. What improvements would you like to see? 14. Do you think Management should continue with Regenix? * Yes No Any additional comments or suggestions: Submit If you are human, leave this field blank.
