Home Draw Survey

Welcome to our Home Draw Survey.

Your Lab. An Important Choice. Thanks for choosing URMC Labs and contributing to our continuous improvement effort by sharing your opinion.

Please note that all mandatory questions (as denoted by a red asterisk) must be answered in order for your feedback to be utilized.

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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

*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

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