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This is the questionnaire that deals with health care and your involvement in health care. Please take a few minutes to express your opinions about the availability and quality of health care in your community. Your answers are important to the success of this study.
Thank you for your assistance. |
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| Please tell us the city, state (or territory), and country you live | | |
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| Is there a difference in performance between the available hospitals in this area? |
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| Do you have a preferred hospital? |
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| Is there a difference in the cost of the hospitals in this area? |
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| Do you receive pressure from other family members to get health care problems taken care of promptly? |
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| Do you feel comfortable judging the differences between hospitals in this area? |
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| Do you receive care from the same hospital? |
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| Can you be helpful to friends who are having difficulty making section of a hospital? |
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| How many years have you lived in this community? | | |
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| How satisfied are you with the skill and competency of the staff? |
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| Does the hospital you regularly visit have equipment for modern diagnosis and treatment? |
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| Does the hospital have modern operating room facilities? |
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How satisfied are you with the following:
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| Overall cleanliness of the hospital |
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| Efficiency of nursing care |
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| Friendliness and courtesy of staff |
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| Convenience of location for you |
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| What kind of medical insurance coverage do you have? |
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| How many times have you and any member of your family been to your doctor in the last year? | | |
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| How many times have you visited a friend or loved one in the hospital in the last year? | | |
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| How many times have you and other members of your family been a patient in a hospital in the last 3 years? | | |
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| If quality of service is equal, which source of care would you prefer? |
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| If you or a member of your family have received medical care at another hospital while living in the [HOSPITAL] area, why did you choose the other hospital? |
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| When making health care decisions for your family, who is the primary decision maker? |
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| From your experience in the past, when you or a member of your family needs hospital care, who decides on the hospital? |
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| What have you heard about the care patients receive at [Hospital]? | | |
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| The last section of the questionnaire contains a series of questions about your demographic characteristics such as age and income. We are asking these questions in order to determine if various groups have different opinions and attitudes about hospital care. Please answer these personal questions. No one will ever associate these responses with your name. |
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| Age(s) of children living in your household: (Check all that apply) |
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| Total household income (from all sources) before taxes for the year [Year]? |
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| Highest level of formal education that you have completed. |
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| Spouse's primary occupation? | | |
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| Thank you for your assistance. |
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