HHCPI-ADM-FRM-001v.

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HHCPI CUSTOMER SATISFACTION SURVEY

Home Health Care Placements, Inc. is committed to improving its services and care to our clients and
patients. Your feedback will help and guide us in sustaining and continuously improving this
commitment. Please take a few minutes to answer this Customer Satisfaction Survey form (CSS).

Please encircle the rating applicable to your assessment:

Please rate the Vaccination Service Provider 1 2 3 4 5
during the event. Very Poor Poor Good Very Good Excellent
1. Health Care Professional starts on time 1 2 3 4 5
2. Health Care Professional wears proper 1 2 3 4 5
uniform, neat, hygienic
3. Professionalism 1 2 3 4 5
4. The Doctor/Nurse asked service/product- 1 2 3 4 5
related questions, explained the benefits, risks
and provided health teaching
5. The work station is organized and in a well 1 2 3 4 5
arranged manner
6. OVERALL RATING 1 2 3 4 5

Will you recommend Home Health Care to others? Yes ☺ No ☹

We would appreciate if you could write your comments/suggestions for improving Company Name
our service
Name/Signature of Company
Representative

Date Contact Number

Date Name of HCP/Signature TIME TIME No. of Vaccines Received

IN OUT
No. of Client Vaccinated
MD
MD No. of Vaccine Endorsed

RN
Received by
RN

Name of Assigned HHC Case Manager:

Date of effectivity: 01-15-2016