Scoring Reference

5 — Excellent: Proactively exceeded standard

4 — Good: Fully met standard

3 — Adequate: Partially met standard

2 — Poor: Significantly below standard

1 — Unacceptable: Standard completely absent

N/O — Not Observed during this visit

Facility Assessment Details

Fields marked * are required before you can submit. Complete all details carefully — they will appear in your final report.

Facility Name *

Facility Type *

Visit Date *

Visit Day

Arrival Time *

Departure Time

Shopper Reference Code *

Shopper Profile Used *

Visit Scenario / Complaint Used *

Department(s) Visited *

OPEX Engagement Reference *

Visit Number (in this cycle)

Pre-Visit Notes / Special Instructions from OPEX

General Observations & Shopper Reflection

Record your overall impressions, moments that stood out, and anything not captured in the scored criteria.

First Impression (arrive to first acknowledged)

Most Positive Moment of the Visit

Most Disappointing Moment

Staff Attitudes & General Culture

Physical Environment Overall

Any Patient Safety Concerns Observed

What Would Bring You Back as a Paying Patient?

Specific Staff Conduct Worth Flagging to OPEX (do NOT include names — describe role, department, approximate time)

Shopper Overall Experience Rating *

Shopper Signature / Initials *

Date Submitted *

Time Submitted *

Once submitted, your assessment is securely sent to the OPEX team. You do not need to print or export anything.