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| Which community (or rural area) do you live? | | |
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| Is there a wide difference in performance between the available hospitals in this area? |
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| Do you have a favorite hospital? |
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| Is there a wide difference in the cost of the different hospitals in this area? |
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| Do you feel comfortable judging the differences between hospitals in this area? |
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| Do you generally receive care from the same hospital? |
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| How satisfied are you with the skill and competency of the staff? |
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| Does the hospital 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 the staff |
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| Convenience of location for you |
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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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| Which source of care would you prefer if you had a personal injury that could be handled equally well by each of these sources of health care: |
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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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| Sex of person completing this questionnaire: |
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| Age of person completing this questionnaire: | | |
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| Marital status of person completing this questionnaire: |
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| What was your total household income (from all sources) before taxes for the year [Year]? |
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| Please indicate the highest level of formal education that you have completed. |
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| What is your primary occupation? | | |
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| What is your spouse's primary occupation? | | |
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| Thank you for your assistance. |
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