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return true;" onmouseout="cFrame.tHideAll();changeImages('career_btn', 'images/career_btn.jpg'); return true;"> <IMG NAME="career_btn" SRC="images/career_btn.jpg" WIDTH=86 HEIGHT=28 BORDER=0></a></TD> <form action="SiteSearch.asp" method="post"> <TD background="images/search.jpg" WIDTH=177 HEIGHT=28> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="SiteTextSearch" type="text" value='Search' size="12" maxlength="40" style="color:#97001B; border-color:#D9A2AC; border-style:solid; border-width:1px">&nbsp; <input name="SearchType" type="image" SRC="images/go_btn.gif" onClick="document.forms(0).submit();"> </TD> </form> </TR> <TR> <TD COLSPAN=2> <IMG NAME="hcp_img" SRC="images/ppscl_img.jpg" WIDTH=144 HEIGHT=52></TD> <TD COLSPAN=6> <IMG NAME="hcpfaq_hdr" SRC="images/pss_hdr.jpg" WIDTH=708 HEIGHT=52></TD> </TR> <TR> <TD class="bluesub" bgcolor="b0b0b0" COLSPAN=8 WIDTH=852 HEIGHT=19>&nbsp;<a href="patient_servicecenters.html">Patient Service Center Locations</a> <span class="linkdiv">|</span> <a href="patient_prepfortest.html">Preparation for your test</a> <span class="linkdiv">|</span> <a href="patient_compunetdirect_1.html">Direct Access Testing</a> <span class="linkdiv">|</span> <a href="patient_billing.html">Patient Billing</a> <span class="linkdiv">|</span> <a href="patient_edu.html">Patient Education</a> <span class="linkdiv">|</span> <a href="patient_faq.html">FAQ&rsquo;s</a></TD> </TR> <TR> <TD valign="top" COLSPAN=8 background="images/hcp_content.jpg" WIDTH=852 HEIGHT=586> <table width="100%" border="0"> <tr> <td width="18%">&nbsp;</td> <td width="53%">&nbsp;</td> <td width="29%">&nbsp;</td> </tr> <tr> <td valign="top" align="center" height="111"><img src="images/family_img.jpg"></td> <td class="body" valign="top"> <span class="header2">Patient Satisfaction Survey</span></p> <span class="subheader2">We're Listening!</span><br> As Vice-President of Operations, I want to thank you for giving us the opportunity to service your laboratory needs. Please help us to continue improving our service by completing our brief survey.</p> Thank you for selecting CompuNet Clinical Laboratories!</p> <i>Paul</i><br> Paul Labbe</p><hr style="color:6C92AF" width="60%" align="left" size="1"></p> <TABLE BORDER=0 CELLPADDING=1 CELLSPACING=1> <form name="C3vtJlSh" action="survey.asp" method="POST" onsubmit="return validate_form(this)"> <TR> <TD class="header2" colspan="2"> CompuNet Clinical Laboratories Patient Satisfaction Survey</p></TD></TR> <TR><TD style="font-size: 10pt; font-weight: 700" valign="top" colspan="2"> Name of patient: <span style="color: red" title="Required field">*</span><br /> <INPUT TYPE="TEXT" id="pb3XmZYR" name="k11HsQRh" value="" size="55" class="body"> </TD></TR> <TR><TD style="font-size: 10pt; font-weight: 700" valign="top" colspan="2"> Date of Visit:<br /> <INPUT TYPE="TEXT" id="b3kSSZAD" NAME="Q6LNyEnA" value="" size="55" class="body"> </TD></TR> <TR><TD valign="top" colspan="2"> <span style="font-size: 10pt; font-weight: 700">Location:</span> <span style="font-size: 10pt; font-weight: 700; color: red" title="Required field">*</span><br /> <!-- <input type="text" id="location" name="Location" value="" size="55" class="body"> <span style="color: red" title="Required field">*</span></p> --> <select id="H9GbMt7O" name="c86lQrO3" class="body"> <option value="--[ CHOOSE ]--" SELECTED> --[ CHOOSE ]-- </option> <option value="BEAVERCREEK - 1244 Meadow Bridge Dr. "> BEAVERCREEK - 1244 Meadow Bridge Dr. </option> <option value="BEAVERCREEK - Acropolis at Fairfield Commons - 2601 Commons Blvd. "> BEAVERCREEK - Acropolis at Fairfield Commons - 2601 Commons Blvd. </option> <option value="CENTERVILLE - Miami Valley South Health Center - 2350 Miami Valley Drive "> CENTERVILLE - Miami Valley South Health Center - 2350 Miami Valley Drive </option> <option value="CENTERVILLE - South Med Bldg. - 7707 Paragon Rd. "> CENTERVILLE - South Med Bldg. - 7707 Paragon Rd. </option> <option value="DAYTON - 122 Wyoming St. "> DAYTON - 122 Wyoming St. </option> <option value="DAYTON - Elizabeth Place - 627 S Edwin C Moses Blvd "> DAYTON - Elizabeth Place - 627 S Edwin C Moses Blvd </option> <option value="DAYTON - InterMed Bldg. - 1520 S. Main St. "> DAYTON - InterMed Bldg. - 1520 S. Main St. </option> <option value="DAYTON - Miami Valley Hospital - Berry Bldg. - One Wyoming St. "> DAYTON - Miami Valley Hospital - Berry Bldg. - One Wyoming St. </option> <option value="DAYTON - Miami Valley Hospital - Outpatient Lab - One Wyoming St. "> DAYTON - Miami Valley Hospital - Outpatient Lab - One Wyoming St. </option> <option value="EATON - 200 Eaton Lewisburg Road "> EATON - 200 Eaton Lewisburg Road </option> <option value="ENGLEWOOD - Palmer Building - 5 W. Wenger Rd. "> ENGLEWOOD - Palmer Building - 5 W. Wenger Rd. </option> <option value="HUBER HEIGHTS - 8638 Old Troy Pike "> HUBER HEIGHTS - 8638 Old Troy Pike </option> <option value="KETTERING - Claybourne Bldg. - 1525 E. Stroop Rd. "> KETTERING - Claybourne Bldg. - 1525 E. Stroop Rd. </option> <option value="KETTERING - Park Place Bldg. - 540 Lincoln Park Dr. "> KETTERING - Park Place Bldg. - 540 Lincoln Park Dr. </option> <option value="LIMA - Internal Medicine Specialties Draw Site - 920 W. Market St. Suite 210 "> LIMA - Internal Medicine Specialties Draw Site - 920 W. Market St. Suite 210 </option> <option value="LIMA - St. Rita's Delphos Ambulatory Center - 1800 East 5th Street "> LIMA - St. Rita's Delphos Ambulatory Center - 1800 East 5th Street </option> <option value="LIMA - St. Rita's East Side Urgent Care - 967 Bellefontaine Ave "> LIMA - St. Rita's East Side Urgent Care - 967 Bellefontaine Ave </option> <option value="LIMA - St. Rita's West Side Urgent Care - 2195 Allentown Road "> LIMA - St. Rita's West Side Urgent Care - 2195 Allentown Road </option> <option value="MIDDLETOWN - North Breiel Blvd. "> MIDDLETOWN - North Breiel Blvd. </option> <option value="MORAINE - CompuNet Building - 2308 Sandridge Dr. "> MORAINE - CompuNet Building - 2308 Sandridge Dr. </option> <option value="OAKWOOD - 2600 Far Hills Ave. "> OAKWOOD - 2600 Far Hills Ave. </option> <option value="PIQUA - 304 W. High St. "> PIQUA - 304 W. High St. </option> <option value="SPRINGBORO - 6 Sycamore Creek Dr. "> SPRINGBORO - 6 Sycamore Creek Dr. </option> <option value="SPRINGFIELD - North - Crystal Clear Imaging - 2100 Emmanuel Way, Ste. C "> SPRINGFIELD - North - Crystal Clear Imaging - 2100 Emmanuel Way, Ste. C </option> <option value="SPRINGFIELD - South - 2105 E. High St. "> SPRINGFIELD - South - 2105 E. High St. </option> <option value="TROY - 1850 W. Main St. "> TROY - 1850 W. Main St. </option> <option value="URBANA - 848 Scioto Street "> URBANA - 848 Scioto Street </option> <option value="VANDALIA - 900 South Dixie Dr. "> VANDALIA - 900 South Dixie Dr. </option> <option value="XENIA - 1214 N. Monroe Dr. "> XENIA - 1214 N. Monroe Dr. </option> <option value="OTHER (Please provide detail) "> OTHER (Please provide detail in comment section below) </option> </select> </TD></TR> <TR><TD valign="top" class="body" colspan="2"> <span style="font-size: 10pt; font-weight: 700">1 - Comfort/Cleanliness of Facility:</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><input type="radio" id="MFGkyy04" name="DtLOoW01" value="5 - Very Good"> </td><td class="body">5 - Very Good</td></tr> <tr><td><input type="radio" id="MFGkyy04" name="DtLOoW01" value="4 - Good"> </td><td class="body">4 - Good</td></tr> <tr><td><input type="radio" id="MFGkyy04" name="DtLOoW01" value="3 - Fair"> </td><td class="body">3 - Fair</td></tr> <tr><td><input type="radio" id="MFGkyy04" name="DtLOoW01" value="2 - Poor"> </td><td class="body">2 - Poor</td></tr> <tr><td><input type="radio" id="MFGkyy04" name="DtLOoW01" value="1 - Very Poor"> </td><td class="body">1 - Very Poor</td></tr> </table> </TD></TR> <TR> <TD valign="top" class="body" colspan=2>&nbsp;</TD> </TR> <TR><TD valign="top" class="body" colspan=2> <span style="font-size: 10pt; font-weight: 700">2 - Did the staff treat you in courteous, professional manner?</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><input type="radio" id="vLdkWHw6" name="vfEFUs3W" value="5 - Very Good"> </td><td class="body">5 - Very Good</td></tr> <tr><td><input type="radio" id="vLdkWHw6" name="vfEFUs3W" value="4 - Good"> </td><td class="body">4 - Good</td></tr> <tr><td><input type="radio" id="vLdkWHw6" name="vfEFUs3W" value="3 - Fair"> </td><td class="body">3 - Fair</td></tr> <tr><td><input type="radio" id="vLdkWHw6" name="vfEFUs3W" value="2 - Poor"> </td><td class="body">2 - Poor</td></tr> <tr><td><input type="radio" id="vLdkWHw6" name="vfEFUs3W" value="1 - Very Poor"> </td><td class="body">1 - Very Poor</td></tr> </table> </TD></TR> <TR> <TD valign="top" class="body" colspan=2>&nbsp;</TD> </TR> <TR><TD valign="top" class="body" colspan=2> <span style="font-size: 10pt; font-weight: 700">3 - Name of Phlebotomist (staff member drawing your blood):</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><INPUT TYPE="TEXT" id="HGWwYE1l" name="yQQMr8Cl" value="" size="55" class="body"></td></tr> </table> </TD></TR> <TR> <TD valign="top" class="body" colspan=2>&nbsp;</TD> </TR> <TR><TD valign="top" class="body" colspan=2> <span style="font-size: 10pt; font-weight: 700">4 - Skill of phlebotomist collecting specimen:</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><input type="radio" id="eDcKu7rt" name="XnGr0Wxs" value="5 - Very Good"> </td><td class="body">5 - Very Good</td></tr> <tr><td><input type="radio" id="eDcKu7rt" name="XnGr0Wxs" value="4 - Good"> </td><td class="body">4 - Good</td></tr> <tr><td><input type="radio" id="eDcKu7rt" name="XnGr0Wxs" value="3 - Fair"> </td><td class="body">3 - Fair</td></tr> <tr><td><input type="radio" id="eDcKu7rt" name="XnGr0Wxs" value="2 - Poor"> </td><td class="body">2 - Poor</td></tr> <tr><td><input type="radio" id="eDcKu7rt" name="XnGr0Wxs" value="1 - Very Poor"> </td><td class="body">1 - Very Poor</td></tr> </table> </TD></TR> <TR> <TD valign="top" class="body" colspan=2>&nbsp;</TD> </TR> <TR><TD valign="top" class="body" colspan=2> <span style="font-size: 10pt; font-weight: 700">5 - Did the Phlebotomist wear gloves while drawing your blood?</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><input type="radio" id="Uo5V6xRk" name="ZL5QYpg0" value="Yes"> </td><td class="body">Yes</td> <td><input type="radio" id="Uo5V6xRk" name="ZL5QYpg0" value="No"> </td><td class="body">No</td></tr> </table> </TD></TR> <TR> <TD valign="top" class="body" colspan=2>&nbsp;</TD> </TR> <TR><TD valign="top" class="body" colspan=2> <span style="font-size: 10pt; font-weight: 700">6 - Did the Phlebotomist wear a lab coat while drawing your blood?</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><input type="radio" id="icU7PfXg" name="d5tfcXqY" value="Yes"> </td><td class="body">Yes</td> <td><input type="radio" id="icU7PfXg" name="d5tfcXqY" value="No"> </td><td class="body">No</td></tr> </table> </TD></TR> <TR> <TD valign="top" class="body" colspan=2>&nbsp;</TD> </TR> <TR><TD valign="top" class="body" colspan=2> <span style="font-size: 10pt; font-weight: 700">7 - How long did you wait to be served?</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><input type="radio" id="D3EdSNyB" name="BmcWpYM3" value="0-10 Minutes"> </td><td class="body">0-10 Minutes</td></tr> <tr><td><input type="radio" id="D3EdSNyB" name="BmcWpYM3" value="11-20 Minutes"> </td><td class="body">11-20 Minutes</td></tr> <tr><td><input type="radio" id="D3EdSNyB" name="BmcWpYM3" value="21-30 Minutes"> </td><td class="body">21-30 Minutes</td></tr> <tr><td><input type="radio" id="D3EdSNyB" name="BmcWpYM3" value="30+ Minutes"> </td><td class="body">30+ Minutes</td></tr> </table> </TD></TR> <TR> <TD valign="top" class="body" colspan=2>&nbsp;</TD> </TR> <TR><TD valign="top" class="body" colspan=2> <span style="font-size: 10pt; font-weight: 700">8 - What was the overall level of care you received during your visit?</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><input type="radio" id="Bk1lvD90" name="yOOJDDz5" value="5 - Very Good"> </td><td class="body">5 - Very Good</td></tr> <tr><td><input type="radio" id="Bk1lvD90" name="yOOJDDz5" value="4 - Good"> </td><td class="body">4 - Good</td></tr> <tr><td><input type="radio" id="Bk1lvD90" name="yOOJDDz5" value="3 - Fair"> </td><td class="body">3 - Fair</td></tr> <tr><td><input type="radio" id="Bk1lvD90" name="yOOJDDz5" value="2 - Poor"> </td><td class="body">2 - Poor</td></tr> <tr><td><input type="radio" id="Bk1lvD90" name="yOOJDDz5" value="1 - Very Poor"> </td><td class="body">1 - Very Poor</td></tr> </table> </TD></TR> <TR> <TD valign="top" class="body" colspan=2>&nbsp;</TD> </TR> <TR><TD valign="top" class="body" colspan=2> <span style="font-size: 10pt; font-weight: 700">9 - Would you recommend CompuNet Clinical Laboratories to a family member or friend?</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><input type="radio" id="tGO3wZ34" name="gilE2703" value="Yes"> </td><td class="body">Yes</td> <td><input type="radio" id="tGO3wZ34" name="gilE2703" value="No"> </td><td class="body">No</td></tr> </table> </TD></TR> <TR> <TD valign="top" class="body" colspan=2>&nbsp;</TD> </TR> <TR><TD valign="top" class="body" colspan=2> <span style="font-size: 10pt; font-weight: 700">10 - Would you like a return call concerning your visit?</span> <table border=0 cellpadding=1 cellspacing=1> <tr><td><input type="radio" id="eMBJyd0i" name="d05vA57J" value="Yes"> </td><td class="body">Yes</td> <td><input type="radio" id="eMBJyd0i" name="d05vA57J" value="No"> </td><td class="body">No</td></tr> </table> </TD></TR> <TR> <TD class="body" align="right" valign="top">&nbsp;</TD> <TD valign="top">&nbsp;</TD> </TR> <TR><TD style="font-size: 10pt; font-weight: 700" align="left" valign="top" colspan="2"> Contact Name (if other than patient):<br /> <INPUT TYPE="TEXT" id="iAdEe5OU" name="mbsC22xT" value="" size="55" class="body"> </TD></TR> <TR><TD style="font-size: 10pt; font-weight: 700" align="left" valign="top" colspan="2"> Phone:<br /> <INPUT TYPE="TEXT" id="kBkS5zCM" name="dCr8wMKl" value="" size="55" class="body"> </TD></TR> <TR><TD style="font-size: 10pt; font-weight: 700" align="left" valign="top" colspan="2"> Comments or Suggestions:<br /> <textarea id="GBK7MEyD" name="lW4iFEIC" rows="6" cols="65" wrap="virtual" onKeyDown="countchar(this)" onKeyUp="countchar(this)" ></textarea><br /> <!-- <textarea id="GBK7MEyD" name="lW4iFEIC" rows="4" cols="55" wrap="virtual" ></textarea><br /> --> <span style="font-size: 10pt;">(</span>You're comment is <span id="txtvar" name="txtvar" style="font-size: 10pt;">0</span> <span style="font-size: 10pt;"> characters long)</span> </TD></TR> <TR><TD></TD> <TD class="body"> <INPUT TYPE="SUBMIT" VALUE="SEND" id="U796cB53" name="Uqt1LTg9"><br /> <span style="color: red" title="Required field">*</span> = This is a required field. </TD></TR> </FORM> </TABLE> </td> <td valign="top"> <table width="86%" border="0"> <tr> <td valign="top" height="257" background="images/ppsclsml_greybox.gif"> <table width="99%" border="0"> <tr> <td width="4%"></td> <td width="95%" class="body"> <span class="subheader2A">CLIENT SERVICES</span><br> We are also available to answer any questions you may have.</p>Telephone <span class="inline2">(937) 297-8260.</span><br> Outside Dayton, but within Ohio: <span class="inline2">1-800-686-2252.</span> </td> </tr> </table> </td> </tr> </table> </td> </tr> </table> </TD> </TR> <TR> <TD WIDTH=852 HEIGHT=42 COLSPAN=8 bgcolor="#E6E6E6" class="legal"> <center>CompuNet Clinical Laboratories, LLC. &nbsp;All rights reserved. <a href="pdf/CompuNet_Clinical_Laboratories_Privacy_Statement.pdf" style="font-size:10px; color:#7D7D7D "target="_blank"> Privacy Notice</a><br> 2308 Sandridge Drive &nbsp;Moraine, Ohio 45439<br> CompuNet and its associated logo are registered trademarks of CompuNet Clinical Laboratories, LLC.</TD> </TR> </TABLE> <!-- End Image Slices --> </BODY> </HTML>