Home Draw Survey

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Survey

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*1.	Please enter the red number near the upper left hand corner of your survey

*2.	Please enter the date of your home draw in MM/DD/YYYY (Month/Day/Year) format

	Remaining characters: 10

*3.	Please select the time of your home draw

4.	Please enter your phlebotomist's name (if known)

*5.	My phlebotomist displayed a neat and professional appearance

*6.	My phlebotomist introduced him/herself and had proper identification visible

*7.	A phone call was placed the day prior to inform me of my scheduled home draw

*8.	I was given a time frame within which the phlebotomist would arrive

*9.	I was treated with courtesy and concern

*10.	Everything was explained clearly

*11.	The needle stick was comfortable

*12.	My overall experience was satisfactory

13.

(Optional) Name, phone number, email address

First Name
Last Name
Home Phone
Cell Phone
Email Address

14.	(Optional) Please provide any additional comments

	Remaining characters: 4000

15.	(University of Rochester Medical Center Staff Only) Please enter the code for internal data entry

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