Shot Room Survey
Family Allergy & Asthma and Arkansas Allergy & Asthma Clinic
*
1.) Which shot room did you visit?
0
/50
*
2.) Did the staff greet you?
Yes
No
*
3.) Once you scanned your card, approximately how long did you wait before being called for your shot?
0 - 4 Minutes
5 - 8 Minutes
9+ Minutes
*
4.) Did the shot room staff call you by your first name only?
Yes
No
*
5.) Did the shot room staff confirm your date of birth prior to giving you your shot?
Yes
No
*
6.) Were you asked about any problems with breathing prior to receiving your shot?
Yes
No
*
7.) Is the waiting room kept neat and clean?
Yes
No
*
8.) Is there adequate seating available in the waiting room?
Yes
No
*
9.) Is the shot room appropriately staffed to handle the number of shot patients?
Yes
No
10.) Do you have any additional comments or feedback?
0
/500
Submit Survey
