Georgian Nurse Practitioner Led Clinic (NPLC) Patient Survey
All information will be kept confidential. When you are finished please return the completed survey to the front desk
1. Since joining Georgian NPLC how may visits have you had in total? Less than 3 ☐ 3 or more ☐
3. The last time you were sick or were concerned
you had a health problem, how many days did it
take from when you first tried to see your Nurse
Practitioner to when you actually SAW him/her or
someone else in their office?
☐Same day
☐Within 24hrs
☐Within one week
☐More than a week
☐Not applicable/unsure
2. Who have you seen when visiting the clinic?
(Check all that apply)
☐ Nurse Practitioner
☐ Registered Nurse
☐ Social Worker
☐ Registered Dietitian
☐ Collaborating Physician ☐ Ontario Telemedicine
4. The clinic is open Monday to Friday 8am to 4.30pm and
Wednesday evenings until 8pm. Do these hours meet your
needs? If NOT, what hours would better meet your needs?
☐Yes ☐No
Comment:_____________________________________
5. Please answer yes or no to the following questions
a. The front desk act professionally
☐Yes ☐No
b. I know where I can make a suggestion or complaint?
☐Yes ☐No
6. When you see your Nurse Practitioner, how often do they, or someone else in their office:
(where on a scale of 1 to 5: 1 is always, 2 is often, 3 is rarely, 4 is never and 5 is not applicable
…Give you an opportunity to ask questions
about recommended treatment
1
2
3
4
5
…involve you as much as you want to be in decisions
about your care and treatment
1
2
3
4
5
…spend enough time with you
1
2
3
4
5
Please answer the following about your overall experience since joining the Georgian NPLC:
7. Overall, are you satisfied with the service/care you receive at the Georgian NPLC? ☐Yes
8. Would you recommend the Georgian NPLC to family and/or friends? ☐Yes
☐No
☐No
9. Please share your opinion on what is unique or special about the service/care you receive at the Georgian NPLC
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Thank-you for your feedback. Please return your completed survey to the box at the front desk.
References:
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Adapted from: The Huronia NPLC Patient Feedback Survey (2013)
Georgian College Students for Huronia NPLC Patient Survey (2013)
Stanik-Hutt. J., Newhouse, R. et al. (2013) The Quality and Effectiveness of Care Provided by Nurse Practitioners, The Journal for Nurse
Practitioners, 9, 8, 492-499.
Sidani, S. and Doran, D. (2010). Relationships Between Processes and Outcomes of Nurse Practitioners in Acute Care, Journal of Nurse
Care Quality, 25,1, 395-402.
Wong, S and Peterson, S. et al. (2011). Patient Activation in Primary Healthcare, Medical Care, 49, 5, 469-479.