Course Project

Dear respondent:

You have been picked randomly via the use of probability techniques to
participate in this research project. Therefore, your full participation will be
highly appreciated.

The findings generated in this study will be handled with the highest level of
confidentiality and for this academic exercise only.

HealthCare Questionnaire
Medical Staff in Hospital or Clinic
(Health Facility)

ICU

(CBMS 2017)

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Please respond to the following questions as truthfully as possible. Where
there are options provided, select the appropriate response by putting a tick
[√] in the box of your choice.

A. GEOGRAPHICAL INFORMATION

Q. id Question Response For official use

A1 Province ……………………………
A2 District …………………………….
A3 Constituency …………………………….
A4 Ward …………………………….
A5 Population Density
1. High
2. Medium
3. Low
A6 Enumeration Area ……………………………
A7 Residence (of the institution)

1. Rural
2. Urban

B. INSTITUTIONAL INFORMATION

Name of Institution
B1
Ownership of the Institution
1. Private
B2 2. public
Description of job title
1. Doctor
B3 2. Clinical officer
3. Nurse
4. …………

C. SERVICES OFFERED

Does your health facility offer any of the following Ye No

service? Please tick (√) what applies s
C1 Laboratory (screening)
C2 Intensive Care Unit (ICU)
C3 Outpatient emergency
C4 X-Ray
C5 Chemotherapy
C6 Specialist section: Cervical cancer, eye, dental,
TB, Maternity, Inpatient, Dispensation, etc.
C7 Counseling
(HIV/AIDS, VCT, smocking, Dietary, etc.)

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 C8 Surgery (Surgical operations)
C9 Screaming
(Diabetes, blood pressure, etc.)
C10 Inpatients section

D. Assessment of the SNPD Indicators

How do you evaluate the attainment of the following SNDP indicators at

your health facility (estimates)
Key Health Performance Indicator
100 75% 50% 25 0%
% High Moderate % Very
Very Low Low
High
F1 Under-five Mortality rate
(per 1,000 live births)
F2 Maternal Mortality Ratio
(per 100,000 live births)
F3 Proportion of rural
households living within 5km
of the nearest health facility
F4 Incidence of malaria
(per 1,000 population )
Malaria Case Fatality Rate
F5 among Children (below the
age of 5 years)
Percent of Fully Immunized
F6 Children (under one year of
age)
F7 Percent of deliveries assisted
by skilled health personnel

E. HEALTH PROMOTION

How do you evaluate the Prevalence rate of the following

(within your institution)
Very Hig Moderate Low Very
High h 50% 25 Low
100% 75% % 0%
G1 Under-age pregnancy
G2 Smoking rate
G3 Gonorrhea/Chlamydia
rates
G4 Abortion rates
G5 Malnutrition prevalence
G6 HIV/AIDS prevalence
G7 Syphilis prevalence
G8 Child mortality
G9 Maternal mortality

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G10 Infant mortality
G11 Fertility/ Birth rate
G12 Underweight children
G13 Cervical cancer
G14 Malaria prevalence
G15 Tuberculosis prevalence

F. ASSSESSMENT OF THE SNDP OJCTIVES

How would you rate the effectiveness of the following programs at your
institution
(Please tick (√) what applies)
Very High Moderat Low Very
High 75% e 25% Low
100 50% 0%
%

I1 Provision of outreach services

I2 Mobile Hospital Services
I3 Malaria prevention and control
I4 Access to TB Control and
Prevention programmes
I5 Promote Health Education in the
prevention and control of diseases
I6 Access to HIV prevention and
treatment services including STIs
and blood safety;
I7 Access to Environmental Health
and Food Safety services;
I8 Expansion of ART services
I9 Expansion of nutrition services
I10 Improve laboratory services
I11 Management and maintenance of
medical equipment
I12 Strengthen capacity for transport
management at all levels of
health care
I13 Improve ICT capacity health
facilities

G. SUGGESTIONS ON HOW TO IMPROVE THE SITUATION

What needs to be done in order to improve the health system at your health
center? (clinic or hospital)
……………………………………………………………………………………………
……………………………………………………………………………………………

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Name of respondent: …………………..…………………………
Signature: ………………………… Date ……………………….

Thank you for participating in this survey!!

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