Fillable J-1 V isa Waiver Program Physician Compliance Survey (Delta Regional Authority)

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J-1 V isa Waiver Program Physician Compliance Survey (Delta Regional Authority)

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DRA Delta Doctors Program – Compliance Survey B (Employee)
Effective: Sep
tember 4, 2020
J-1 V
isa Waiver Program
Physician Compliance Survey Part B (Physician)
Note: Responses to the questions listed on page two and three are strictly confidential. Only
designated staff with the Delta Regional Authority will view the responses to those questions.
Year
: _________________________ Survey Number: ________________
Survey Period: __________________ Survey
Date: ___________________
Name: (print or type)______________________________
Empl
oyment Start Date: _____________________
I-612 Approval Date: _______________________
H-1(b) Approval Date: ______________________
Address: Home: _________________________________ Office:______________________________
Street Street
_________________________________ ______________________________
City/State/Zip City/State/Zip
_________________________________ ______________________________
Home Phone Work Phone
Physician’s E-mail Address: _____________________________________________________________
Name of Worksite (Please provide data for each worksite): _____________________________________
Worksite Address: _____________________________________________________________________
Street/Location City/State/Zip County
Type of Medical Practice: _______________________________________________________________
(Example: General Practice, Family Medicine, Pediatrics, etc.)
DRA Delta Doctors Program – Compliance Survey B (Employee)
Effective: September 4, 2020
Please indicate the number of patients that you have seen in the past six months.
Tota
l No. of Patients: ____________________
No. of Private Pay Patients: _______________ % of Total Patients: ________________
No. of Medicare Patients: _________________ %of Total Patients: _________________
No. of Medicaid Patients: _________________ % of Total Patients: _________________
No. of Indigent Patients: __________________ % of Total Patients: _________________
No. of Other Patients: ____________________ % of Total Patients: _________________
Please indicate the number of patients that the facility has treated in the past six months.
Tota
l No. of Patients: ____________________
No. of Private Pay Patients: _______________ % of Total Patients: _________________
No. of Medicare Patients: _________________ %of Total Patients: _________________
No. of Medicaid Patients: _________________ % of Total Patients: _________________
No. of Indigent Patients: __________________ % of Total Patients: _________________
No. of Other Patients: ____________________ % of Total Patients: _________________
I hereby certify that I, the undersigned, do provide direct patient care at the above stated worksite(s) for 40
hours per week, or 160 hours per month. I further attest that the information above is truthful and accurate.
Physician’s Signature_______________________________________ Date:_________________
Please answer the following questions in accordance with the indicated scale:
4=Excell
ent, 3=Good, 2=Average, 1=Poor
1. How would you rate your overall experience with the medical facility described above thus far?
_________________
2. How would you rate the way the administrator(s) of the medical facility has followed the terms set
forth in the employment contract? _________________
3. How would you rate the way that you have been treated by the administrator(s) of the medical
facility described above? ____________________
4. How would you rate the way you have been accepted by patients at the medical facility described
above? ________________
5. How would you rate the way you have been welcomed by the local community?
______________
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DRA Delta Doctors Program – Compliance Survey B (Employee)
Effective: Sep
tember 4, 2020
Please use the space provided to make any positive statement or comment on any problem or
concern that you have in regard to the medical facility listed above.
Please Return Form To:
Delta Regional Authority
Attention: Delta Doctors Program
236 Sharkey Avenue, Suite 400
Clarksdale, MS 38614
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J-1 V isa Waiver Program Physician Compliance Survey (Delta Regional Authority)

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Completed 25 January 2021

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