Injured Employee Satisfaction Survey

Were you contacted regarding your work-related injury and was the role of the network explained by the IMO network?*

Yes
No

On a scale of 1 to 5 where 1 is minimal time and 5 is too much time, how long did it take between scheduling an appointment with a network treating doctor and actually seeing the doctor?*

On a scale of 1 to 5 where 1 is minimal amount of time and 5 is too much time, how long was your wait time from arriving at the doctor’s office and being taken back to the exam room?*

Your treating doctor for your work-related injury or illness (check all that apply):*

Wait time was acceptable
Gave a thorough medical examination
Explained your medical condition to easily understand
Seemed willing to answer any medical or treatment questions
Talked to you about a mutually agreed upon return to work date
Overall, provided you with excellent medical care that met your needs

Are you currently employed and working?*

Yes
No

Has your current treating doctor (please select one):*

Released you to go back to work without any physical restrictions
Released you to go back to work with certain physical restrictions
Not released you to go back to any type of work

Approximately how much time were you off work due to your work-related injury or illness? (provide number of weeks; enter 0 for less than a week):*

General Comments or Suggestions

Please contact me for further comments

Yes
No

Name

Phone

Email

Employer*

* This form is for INJURED EMPLOYEE use only. IMO Med-Select Network^® Claims Only. *

Solutions

Network Resources

IMO Connect

*** This form is for INJURED EMPLOYEE use only. IMO Med-Select Network® Claims Only. ***

Solutions

Network Resources

IMO Connect

* This form is for INJURED EMPLOYEE use only. IMO Med-Select Network^® Claims Only. *