Shot Room Survey: Family Allergy & Asthma and Arkansas Allergy & Asthma Clinic
RequiredRequired Question(s)
Required 1.
Which shot room did you visit?
 

50 characters left.
Required 2.

Did the staff greet you? 

Yes
No
Required 3.

Once you scanned your card, approximately how long did you wait before being called for your shot?

0-4 min
4-8 min
8+ min
Required 4.
Did the shot room staff call you by your first name only?
Yes
No
Required 5.

Did the shot room staff confirm your date of birth prior to giving your shot?

Yes
No
Required 6.

Were you asked about any problems with breathing prior to receiving your shot?

Yes
No
Required 7.

Is the waiting room kept neat and clean?

Yes
No
Required 8.

Is there adequate seating available in the waiting room?

Yes
No
Required 9.

Is the shot room appropriately staffed to handle the number of shot patients?

Yes
No
10.

Do you have any additional comments?

 

350 characters left.