QAPI Program Utilization_Manual

CUSTOMER SERVICE PHONE MONTHLY QUESTIONNAIRE NAME: ____________________________ PHONE:___________________________ DATE OF CALL_____________________ COORDINATOR #: _________________ SN: _______________________________ HHA:_______________________________ OTHER:___________________________ ___________________________________ 1. Is the service you are receiving to your satisfaction? El servicio que recibe es satisfactorio? Yes / No Comments : ____________________________________________ _________________________________________________________________ _________________________________________________________________ 2. How many times has the ______ gone this week? ____________ Cuantas veces la _____ ha ido esta semana? __________ (Should have gone ____________times) (Debe haber ido _______veces) 3. How many times has the ______ gone this week? ___________ Cuantas veces la _______ ha ido esta semana? __________ (Should have gone ___________ times? (Debe haber ido __________ veces? 4. H ow many times has the _______ gone this week? _________ Cuantas veces la _______ ha ido esta semana? __________ (Should have gone ____________ times) (Debe haber ido _________ veces Comments :______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3.Is there anything we can do to improve the service you are receiving? Yes / No Que pudieras hacer para mejorar el servicio que recibe? Comments: __________ __________________________________________________________________ __________________________________________________________________ ************************************************************************ For official use: Does any action need to be taken? Yes / No Comments:_________________________ ________________________________________________________________________ 78