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Pax Et Lux
Seal of Tufts University
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Tufts University School of Dental Medicine
Patient Centered Education
Committed to Excellence

Dear Tufts Dental School Patient:

   We would like to make your dental care at Tufts as professional
and efficient as possible. Please take a few minutes to fill out this
survey to give us your opinion on the treatment you have received from
student doctors, faculty and staff. All responses will be
confidential.

   Thank you very much for taking the time to complete this survey.
With your feedback, we will have important information to help us
improve our service to you.
Sincerely,
Lonnie Norris, D.M.D., M.P.H.
Dean

Please return to:
XXXXXXXXX Room 335
or leave completed surveys at the Front Desk
One Kneeland Street
Boston Massachusetts 02111

Sigillum Universitatis Tuftensis
Pax Et Lux
Seal of Tufts University
Peace and Light
http://www.answers.com/topic/tufts-seal-png-1

Tufts University
School of Dental Medicine
Survey of Professional Attitudes and Care

Please mark boxes clearly with an X in dark ink
or with a number two pencil.
Please do not fold.

Today's Date: __________
Time of Day:
[ ]Morning
[ ]Afternoon
[ ]Evening

Today's Treatment: ________________________________________
You are a patient in which group practice?
(circle the number of the practice)
[ ]1  [ ]2  [ ]3  [ ]4  [ ]5  [ ]6  [ ]7  [ ]8

I. Check-In Area
    1. Please indicate your level of agreement with each of
       the following statements about the check-in area.

       a. The waiting room area was comfortable.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       b. The restrooms were clean.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       c. The patient check-in staff was friendly.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       d. The patient check-in staff was knowledgeable.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       e. Overall, the patient check-in staff behaved in a
          professional manner.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

    2. If you could make one suggestion, how would you improve the
       waiting room area or the service from the patient check-in
staff?

_________________________________________________________________

_________________________________________________________________

09/2001
REV. 09/2003

II. Student Doctors
    3. Please indicate your level of agreement with each of
       the following statements about your student doctor.

       a. My student doctor was courteous and kind.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       b. My student doctor explained today's
          procedure clearly to me.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       c. My student doctor listened carefully to my concerns.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       d. My student doctor addressed all of my concerns.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       e. My student doctor performed the procedure with gentleness.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       f. I feel comfortable talking with my student doctor.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       g. It is easy to contact my student doctor by telephone.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       h. My student doctor responds to voice mail messages
          in a timely fashion.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

    4. My student doctor directed me to the Business Office.
       [ ]Yes
       [ ]No

    5. If you could make one suggestion to improve
       the service from your student doctor, what would it be?
       _______________________________________________________
       _______________________________________________________

III. Faculty Supervisors
    6. Please indicate your level of agreement with each of
       the following statements about the faculty supervisors.

       a. The faculty supervisors were courteous and kind.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       b. The faculty supervisors listened carefully to my concerns.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       c. The faculty supervisors addressed all of my concerns.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       d. The faculty supervisors performed the procedure with
gentleness.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       e. The faculty supervisors arrived in a timely fashion.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       f. The faculty supervisors interacted well with my student
doctor.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

    7. If you could make one suggestion to improve
       the service from faculty supervisors, what would it be?
       _______________________________________________________
       _______________________________________________________

IV. Practice Assistant
    8. Please indicate your level of agreement with each of
       the following statements about your practice assistant.

       a. The practice assistant was friendly.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       b. The practice assistant was knowledgeable.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       c. The practice assistant answered the telephone in a
          courteous and timely manner.
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

    9. My practice assistant directed me to the Business Office.
       [ ]Yes
       [ ]No

V. Business Office
   Please indicate your level of agreement with each of
   the following statements about your practice assistant.

   10. The Business Office (payments, insurance information)
       has been responsive to my needs.
       [ ]1 Strongly Disagree
       [ ]2 Disagree
       [ ]3 Agree
       [ ]4 Strongly Agree
       [ ]5 Does Not Apply

   11. The Business Office explained payment policies clearly.
       [ ]1 Strongly Disagree
       [ ]2 Disagree
       [ ]3 Agree
       [ ]4 Strongly Agree
       [ ]5 Does Not Apply

VI. General Information

   12. How many years have you been a patient at Tufts Dental School?
       [ ]a. Less than one year
       [ ]b. One to two years
       [ ]c. Two to five years
       [ ]d. More than five years

   13. If you've been a patient for more than two years, have you
       recognized a change in the way your care has been provided?
       [ ]Yes
       [ ]No

       a. If yes, how would you rate your satisfaction with this
change?
          [ ]1 Strongly Disagree
          [ ]2 Disagree
          [ ]3 Agree
          [ ]4 Strongly Agree
          [ ]5 Does Not Apply

       b. If yes, please specify the change(s) you've perceived:
          ______________________________________________________
          ______________________________________________________

   14. If you have had more than one procedure at Tufts Dental
School,
       did you have the same student doctor for each procedure?
       [ ]Yes
       [ ]No

   15. After my first visit to the dental school,
       I left with an appointment.
       [ ]Yes
       [ ]No

Please indicate your level of agreement with each of
the following statements about the school's clinics.

   16. My appointments have been made efficiently.
       [ ]1 Strongly Disagree
       [ ]2 Disagree
       [ ]3 Agree
       [ ]4 Strongly Agree
       [ ]5 Does Not Apply

   17. It was easy to get information when I first contacted
       the school by phone.
       [ ]1 Strongly Disagree
       [ ]2 Disagree
       [ ]3 Agree
       [ ]4 Strongly Agree
       [ ]5 Does Not Apply

   18. It is convenient to be treated in the same practice
       area of the clinic for most of my needs.
       [ ]1 Strongly Disagree
       [ ]2 Disagree
       [ ]3 Agree
       [ ]4 Strongly Agree
       [ ]5 Does Not Apply

   19. Do any of the following brother you?
       (Please check appropriate response)

       a. Amount of time waiting to check in.
          [ ]Yes
          [ ]No

       b. Amount of time waiting to make your next appointment.
          [ ]Yes
          [ ]No

       c. Amount of time waiting to see your student doctor.
          [ ]Yes
          [ ]No

       d. Amount of time spent in the dental chair.
          [ ]Yes
          [ ]No

       e. Other (please specify):
          _______________________

VII. Patient Information

   20. How old are you? ____years
   21. Sex:
       [ ]Male
       [ ]Female

   22. What is your highest level of education?
       [ ]Less than high school
       [ ]High School
       [ ]College
       [ ]Graduate Degree

   23. What is your current occupation? (please specify):
       __________________________________________________

   24. If retired, what was your former occupation?
       (please specify):
       ______________________________________________________________

   25. What is your usual method of payment for dental treatments?
       [ ]Cash/Check
       [ ]Credit Card
       [ ]Dental Insurance Co-payment
       [ ]Other (please specify)
          ______________________

   26. Your city and state of residence:
       _________________________________(city)
       _________________________________(state)

   27. For treatments at the Tufts Dental School,
       how far (roundtrip) do you travel?
       _______miles roundtrip

   28. What is your usual mode of transportation to arrive
       at Tufts Dental School?
       [ ]a. Car
       [ ]b. Bus
       [ ]c. Subway/Commuter Train
       [ ]d. Taxi
       [ ]e. Walk
       [ ]f. Other (please specify)
             ______________________

   29. Would you refer a friend or family member to Tufts Dental
School?
       [ ]a. Yes. Why? (please specify):
_______________________________
       [ ]b. No.  Why? (please specify):
_______________________________

   30. Is there anything else you would like to tell us
       about your visit to Tufts Dental School?

Thank you for taking the time to complete this survey.