Fillable J-1 Visa Waiver Program Physician Compliance Survey Part (Delta Regional Authority)

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J-1 Visa Waiver Program Physician Compliance Survey Part (Delta Regional Authority)

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DRA Delta Doctors Program – Compliance Survey A (Employer)
Effective: September 4, 2020
J-1 Visa Waiver Program
Physician Compliance Survey Part A (Employer)
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
of Physician: _________________________________________________________
I-612 Approval Date: ____________________________
H-1(b) Approval Date: ___________________________
Employment Start Date: __________________________
Name of Employer: _____________________________________________________________
Point of Contact: _______________________________________________________________
Phone Number: ___________________________________________
E-mail Address: ___________________________________________
Name of Worksite (Please provide data for each worksite): _____________________________________
Type of Medical Practice: _______________________________________________________________
(Example: General Practice, Family Medicine, Pediatrics, etc.)
Worksite Address: _____________________________________________________________________
Street/Location City/State/Zip County
Please indicate the number of patients that the facility has treated in the past six months.
Total No.
of Patients: ____________________
No. of Private Pay Patients: _______________ % of Total Patients: _______________
No. of Medicare Patients: _________________ % of Total Patients: _______________
0.00%
0.00%
DRA Delta Doctors Program – Compliance Survey A (Employer)
Effective: September 4, 2020
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 physician has seen in the past six months.
Total 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 do hereby certify that Doctor ___________________________________________________ is
employed by ___________________________________________________________________
and provides 40 hours of direct patient care per week, or 160 hours per month.
___________________________ __________________________ ___________________
Employer’s Signature Employer’s Name and Title Date
Please answer the following questions in accordance with the indicated scale:
4=Excellent, 3=Good, 2=Average, 1=Poor
1. How would you rate your overall experience with the physician described above thus far?
_________________
2. How would you rate the way the physician has followed the terms set forth in the employment
contract? _________________
3. How would you rate the physician’s ability to communicate effectively with other physicians,
nurses, patients, etc.? ______________
4. How would you rate the way the physician has been accepted by patients at your medical facility?
________________
5. How would you rate the way the physician has been welcomed by the local community?
________________
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
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DRA Delta Doctors Program – Compliance Survey A (Employer)
Effective: September 4, 2020
Please
use the space provided below to make any positive statement or comment on any problem or
concern that you have in regard to the physician described 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 Visa Waiver Program Physician Compliance Survey Part (Delta Regional Authority)

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Completed 25 January 2021

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