DRA Delta Doctors Program - Compliance Closing Survey 

Effective: September 4, 2020 

Delta Doctors Program 

Physician Compliance Closing Survey 

Note: Responses to the questions on this survey are strictly confidential. Only designated staff with 

the Delta Regional Authority will view the responses to the following questions.

Date: ____________________________ 

Name: (print or type) __________________________________________________ 

Years Served: _____________ Employment Start Date:_______________ 

Address: Home:______________________________ Office:___________________________ 

Street Street 

______________________________ ___________________________ 

City/State/Zip City/State/Zip 

______________________________ ___________________________ 

Home Phone Work Phone 

Physician’s E-mail Address: ______________________________________________________________ 

Name of Employer: _____________________________________________________________________ 

Address: ______________________________________________________________________ 

Street/Location City/State/Zip County 

Type of Medical Practice: ________________________________________________________________ 

(Example: General Practice, Family Medicine, Pediatrics, etc.) 

I hereby certify that I, the undersigned, provided direct patient care for the above listed employer for 40 

hours per week, or 160 hours per month, at a worksite(s) located within a HPSA or MUA. I further attest 

that the information above is truthful and accurate. 

I hereby acknowledge that all information and statements contained herein are true and do not misrepresent 

facts, per requirements of 18 USC 1001 (Title 18, U.S. Code, Part 1, Chapter 47, Section 1001). I further 

acknowledge that I have not evaded or suppressed any information contained in this document or in any of 

the supporting materials. 

Physician’s Signature: __________________________________________________ 

Date: __________________________________________________ 
DRA Delta Doctors Program - Compliance Closing Survey 

Effective: September 4, 2020 

Please answer the following questions:

1. Rate your overall experience with the Delta Doctors program:

Excellent Good Average Poor 

2. Please list any suggestions you may have to improve the experience of the program?

3. Please list any suggestions you have that would have improved your work experience?

4. After your contracted term is complete, do you plan to continue working at the facility?

5. If not, where do you plan to locate and work next?

6. Would you to continue to practice medicine? If so, what type of medicine would you

practice?

7. Please list the reasons why you are leaving your current location.

8. Please list the reasons that would remain at your current location. (higher salary, becoming

a partner in the facility, better community experience, etc.)
DRA Delta Doctors Program - Compliance Closing Survey 

Effective: September 4, 2020 

Please use the space below to make any positive statement or comment on any problem or concern 

that you have in regard to your overall experience with the Delta Doctors program:

Please Return Form to:

Delta Regional Authority

Attention: Delta Doctors Program

236 Sharkey Avenue, Suite 400

Clarksdale, MS 38614