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CNNH Satisfaction Survey

1. Please indicate your relationship with the patient seen at CNNH:

Please enter an 'other' value for this selection.

3. If you are using this survey to rate a particular CNNH service or department, please let us know which one:

4. Please tell us about the appointments related to the following attributes:

Space Cell	Well Below Average	Below Average	Average	Above Average	Well Above Average
Scheduling appointments
Check-In process
Wait time
Professionalism of staff
Thoroughness of evaluation(s)
Leaving with an understanding of what needs to be done next
Check-Out process
Nurse call back
Requesting prescription refill

5. If there is a CNNH staff person and/or department you feel provided exceptional attention to you and your family, please feel free to share their name(s) and your experience with us:

6. As a patient or a parent of a patient of CNNH we want to make sure that you have access to information and resources that will be helfpul to you in learning more about a neurological concern, knowing what supports exist outside of CNNH and hearing about other families' experiences. There are so many ways we can share these types of resources but it would be helpful to know the BEST way to offer it to you and your family. Please rank, in order of importance, the ways in which we can best deliver information to YOU! Note: for the following table each column is restricted to a single answer across all rows.

	1	2	3	4	5	6
SPAN family resource specialist at CNNH (to answer questions by email or phone)	1	2	3	4	5	6
Family Support Group at CNNH	1	2	3	4	5	6
Informational Workshop - In Person	1	2	3	4	5	6
Webinar	1	2	3	4	5	6
Web Chat (1 hour group Q&A session through the website about a topic. Text only)	1	2	3	4	5	6
Social Media (blogs & updates on Facebook and Twitter)	1	2	3	4	5	6

7. If you are interested in presentations and support groups that would be held in-person, please let us know the best time, generally, to schedule these events (check all that apply).

Mornings
Lunch Hour
Early Evening (i.e., 4:30pm)
Evenings (i.e., 7pm)
Weekdays
Weekends
Other Please enter an 'other' value for this selection.

8. How likely is it that you would recommend CNNH to a colleague or a friend?

9. Please feel free to share any additional comments or suggestions that would allow us to enhance our services and your experience at CNNH in the future:

10. Do we have permission to share your comments anonymously with others (i.e., on our website, in CNNH materials, etc.)?

11. If you would like us to contact you about your experience at CNNH, please offer your name and the best way to contact you:

First Name:
Last Name:
Contact Phone:
E-mail Address: