1. Gender:

Female
Male

2. Age:
17 and under
18 - 22
23 - 29
30 - 39
40 and over

3. Ethnicity:

African-American/Black
Asian-American/Asian/Pacific Islander
European-American/Caucasian/White
Hispanic/Latina/Latino
Native American/Alaska Native/First nations
Other

4. Citizenship status
Domestic (US Citizen or permanent resident)
International

5. Where do you live:

On-campus
Off-campus
Commuter student

6. Classification:
Undergraduate
Graduate

7. Are you attending school:
full-time
part-time

8.What is your classification:
Freshman/First year student
Sophomore
Junior
Senior
Fifth year or more senior
Graduate school

9. Who is responsible for paying for your medical care?
I am
My parents/guardians

10. Are you covered by health insurance?
Yes
No
Not sure

11. Are you covered by a pharmacy prescription plan?
Yes
No
Not sure

12. Is this your first visit to the Student Health Center?
If yes, please wait until you have been seen before completing the questionnaire.
If no, please complete this survey based on your previous experience.
Yes
No

13. If this is not your first visit please mark the number most representative of your visits to the Student Health Center.
2-3 visits
4-5 visits
6-9 visits
10+ visits

14. Please check today's visit:
visit doctor
nurse practitioner
visit nurse
visit health education

15. Do you try to see the same physician or practitioner on each visit?
Yes
No

16. Please rate the services you used as follows:

5 = Excellent
4 = Very Satisfied
3 = Fairly Satisfied
2 = Poor
1 = Very Poor

Appointment Scheduling

5 4 3 2 1

Check In

5 4 3 2 1

Physician Care

5 4 3 2 1

Nurse Practitioner Care

5 4 3 2 1

Nursing Care

5 4 3 2 1

Lab

5 4 3 2 1

Pharmacy

5 4 3 2 1

Pamphlets and information

5 4 3 2 1

Opportunity for follow-up visits

5 4 3 2 1

Check Out

5 4 3 2 1

Infrastructure - Facility

5 4 3 2 1

Helpfulness of staff

5 4 3 2 1

Overall quality of service

5 4 3 2 1

17. My overall impression of the Student Health and Wellness Center is:
Very good
Good
Satisfactory
Fair
Poor
I have no real opinion

18. I would rate the overall reputation of the Student Health
Center among TSU students to be:
Very good
Good
Satisfactory
Fair
Poor
I have no real opinion

19. Would you recommend the Student Health Center to fellow students?
Yes No

20. Please give us your comments about what we are doing right, patient needs that we are not meeting and/or ideas on how we could improve our current level of services with no additional funds:

21. From the list below, please mark the FIVE most likely sources from which you find out information about campus services or events:

The J-TAC
Flyer/Posters on campus free-standing kiosks
Campus-related web sites
Announcements at student organization meetings
University TV
Brochures/pamphlets
Campus bulletin boards in non-residence hall buildings (excluding free-standing kiosks)
Other (specify)
Please contact me (type in email address)

We sincerely appreciate your time and effort in evaluating our care and services.