RFCC Client/Patient Questionnaire

RURAL/FRONTIER WOMEN’S HEALTH COORDINATING CENTERS

CLIENT QUESTIONNAIRE

The questions on this short survey ask about your recent experience with the [NAME] Rural/ Frontier Women’s Coordinating Center. We appreciate your time and attention in answering these questions as best you can. Your responses will help us to improve the services available to women in the [GEOGRAPHIC AREA].

1. How did you find out about the [NAME] Rural/Frontier Women’s Coordinating Center? (Check one)

Local advertisement/notice □

Website □

Friend or family member □

Doctor or other healthcare provider □

Other (please describe)_________________________________________________

2. When you called or visited the website, what service(s) were you interested in learning about?

   1. ____________________________________________________________________

   2. ____________________________________________________________________

   3. ____________________________________________________________________

   4. ____________________________________________________________________

   5. ____________________________________________________________________

3. How helpful was the person you talked to? (Check one)

Very Helpful □

Somewhat Helpful □

Not Helpful □

4. Did the person you talked to give you the information you needed?

Yes □

No □

5. Did the person you talked to give you information about where to go for the service(s) you needed?

Yes □

No □

6. Where did the person tell you to go? (Please give the name of the place or places)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

7. Do you go to the place that was recommended?

Yes □

No □

8. If you went to the place that was recommended, how would you rate your experience there?

Excellent □

Good □

Fair □

Poor □

9. If you did NOT go to the place that was recommended, why didn’t you go?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

10. Would you call the [NAME] RFCC again if you needed assistance in locating healthcare services?

Yes □

No □

If no, why not? _____________________________________________________________

___________________________________________________________________________

11. Do you feel that you can get the healthcare services you need when you need them?

Yes □

No □

If no, what is preventing you from getting these services?

□ Too far away

□ Can’t get an appointment

□ Costs too much

□ Don’t have a way to get there

□ Other (please explain) _____________________________________________

Navigant Consulting Inc. Appendix G

- 2 -