Emergency Room Visit example
This is an example Emergency Room Visit survey. This survey includes questions like:
Are you male or female
What is your age?
Do you have health insurance?
We hope this will help you create your own Emergency Room Visit survey. We
have not tested the validitiy or reliability of this survey. However, you may
use this as a starting point to help your own survey instrument. Feel free to
change and edit any of our survey templates to help you get started.
1) Are you male or female
Select one...
Male
Female
2) What is your age?
Select one...
18-24
25-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66 or older
3) Do you have health insurance?
Select one...
No
Yes
4) Why did you visit the emergency room?
5) What services, other than seeing a physician, did you receive? (check all that apply)
6) What procedures, if any, did you have?
7) How long did you wait in the waiting area to be seen by ER staff?
Select one...
Less than 30 minutes
30 minutes - 1 hour
More than 1 hour
8) How long did you wait in the examination room to be seen by an ER physician?
Select one...
Less than 30 minutes
30 minutes - 1 hour
More than 1 hour
Please tell us how satisfied you were with each of the following.
9) How satisfied were you with the ease of registration?
10) The friendliness of the registration staff?
11) The cleanliness of the waiting area?
12) The comfort of the waiting area?
13) The cleanliness of the exam room?
Please tell us how much you agree or disagree with each of the following statements
14) The nurse was knowledgeable.
15) My nurse fully explained procedures, tests, and/or treatments.
16) My nurse fully explained the procedures to follow for my after-care at completion of my visit.
17) My nurse was friendly and treated me with respect.
18) The doctor was knowledgeable.
19) The doctor was friendly and courteous.
20) I was given complete attention by the doctor.
21) My questions were answered fully.
22) Overall, how satisfied are you with the quality of the care you received at this hospital?
23) Please tell us what, if anything, we can do to improve the emergency room services of this hospital.
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