Nursing/Tech Questionnaire

The following questions will help us with our evaluation process. If you do not feel that you have enough information to answer a question, leave it blank. Thank you for your assistance. Your responses will be confidential.

Physician  ___________________________

Responds promptly when paged or called.

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

Treats and speaks about patients with respect.

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

Tries to solve problems rather than avoiding them.

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

Would be someone I would choose to take care of me or my family.

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

Demonstrates appropriate boundaries for interprofessional relationships.

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

Maintains a positive attitude amidst increased and unanticipated additional work.

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

Establishes highly effective therapeutic relationships with patients and families.

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

Demonstrates professional behavior – respect, compassion, integrity, honesty -  towards patients, families, staff and colleagues.

Strongly agree          Agree            Neutral             Disagree            Strongly disagree