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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.


Please tell us the city, state ( or territor y), and countr y you li ve

Is there a difference in performance between the available hospitals in this area?


Yes
No
Not sure
Do you have a preferred hospital?
Yes
No
Is there a difference in the cost of the hospitals in this area?
Yes
No
Not sure
Do you receive pressure from other family members to get health care problems taken
care of promptly?
Yes
No
Only sometimes
Do you feel comfortable judging the differences between hospitals in this area?
Yes
No
Not sure
Do you receive care from the same hospital?
Yes
No
Not sure
Can you be helpful to friends who are having difficulty making section of a hospital?
Yes
No
Not sure
How many years have you lived in this c ommunity?
How satisfied are you with the skill and competency of the staff?
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
Not sure
Does the hospital you regularly visit have equipment for modern diagnosis and
treatment?
Yes
No
Not sure
Does the hospital have modern operating room facilities?
Yes
No
Not sure
Overall cleanliness of the hospital
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
Not sure
Efficiency of nursing care
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
Not sure
Friendliness and courtesy of staff
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
Not sure
Convenience of location for you
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
Not sure
Cost of health care
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
Not sure
What kind of medical insurance coverage do you have?
None
Private
Employer sponsored
Medicaid
Medicare
Not sure
Other
How many ti mes have you and any member of your family been to your doctor in the las t year ?

How many ti mes have you visited a fri end or loved one i n the hos pital i n the las t year ?

How many ti mes have you and other members of your famil y been a patient in a hospi tal i n the l ast 3 years?

If quality of service is equal, which source of care would you prefer?


I would prefer to go to a walk-in clinic
I would prefer to go to my personal physician
I would prefer to go to the hospital emergency room
Other
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?
A specialist was available
Special hospital care required was not available in the local area
My physician practices there
More familiar with that hospital
Wanted a second opinion from another physician
Religious preference
Cost was too high in the local area
Other
When making health care decisions for your family, who is the primary decision maker?
Male (or husband)
Female (or wife)
Jointly (both husband and wife)
From your experience in the past, when you or a member of your family needs hospital
care, who decides on the hospital?
You usually decide
You decide based on information from your physician
You and your physician decide together
Your physician decides based on information you provide
Your physician decides
Depends on the situation
What have you heard about the car e patients rec ei ve at [H os pital]?

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.
Gender
Male
Female
Age

Age(s) of children living in your household: (Check all that apply)


< 12
12 - 18
18+
Marital status
Married
Widow(er)
Divorced or separated
Have never been married
Total household income (from all sources) before taxes for the year [Year]?
$25,000 or less
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 and over
Highest level of formal education that you have completed.
High school graduate
College graduate
Completed graduate school
PHD

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