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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.
 
 
 
Which community (or rural area) do you live?
   
 
 

* Is there a wide difference in performance between the available hospitals in this area?
 
Yes
 
No
 
Not sure
 

Do you have a favorite hospital?
 
Yes
 
No
 
 

Is there a wide difference in the cost of the different hospitals in this area?
 
Yes
 
No
 
Not sure
 
 

Do you receive considerable amount of 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 generally 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 community?
   
 
 

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 have equipment for modern diagnosis and treatment?
 
Yes
 
No
 
Not sure
 
 

Does the hospital have modern operating room facilities?
 
Yes
 
No
 
Not sure
 
 

How satisfied are you with the following:
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 the 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 to you
 
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 times have you and any member of your family been to your doctor in the last year?
   
 
 
 
How many times have you visited a friend or loved one in the hospital in the last year?
   
 
 
 
How many times have you and other members of your family been a patient in a hospital in the last 3 years?
   
 
 
 
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:
 
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 was required that 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 care patients receive at [Hospital]?
   
 
 
 
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.
 
 
 
Sex of person completing this questionnaire:
 
Male
 
Female
 
 
 
Age of person completing this questionnaire:
   
 
 
 
Age(s) of children living in your household: (Check all that apply)
 
< 12
 
12 - 18
 
18+

 
 
 
Marital status of person completing this questionnaire:
 
Married
 
Widow(er)
 
Divorced or separated
 
Have never been married
 
 
 
What was your 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
 
 
 
Please indicate the highest level of formal education that you have completed.
 
High school graduate
 
College graduate
 
Completed graduate school
 
PHD
 
 
 
What is your primary occupation?
   
 
 
 
What is your spouse's primary occupation?
   
 
 
 
Thank you for your assistance.