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: _______________ 
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?

________________
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