Republic of the Philippines

Province of Cotabato
Municipality of Makilala
MAKILALA INSTITUTE OF SCIENCE AND TECHNOLOGY
Makilala, Cotabato
SURVEY QUESTIONNAIRE

Research Title: ASSESSMENT ON PUBLIC HEALTH SERVICES IN THE MUNICIPALITY OF MAKILALA: A BASIS FOR A
PROGRAM IMPLEMENTATION REPORT

Part I. Socio- Demographic Profile

Name (optional):_________________________________________ Sex: Female

Male

Civil Status: Single Married Widow/ Widower

Economic monthly Income: 5,000 below 5,000 – 10,000

10,000 – 20,000 20,000 – 30,000

30,000 above

Part II. Public Health Services Offered in Makilala

Primary Care Benefit Package (PCB)

Maternity Care Package (MCP)

New born Screening Package

TB – DOTS Package

Out Patient Malaria Package

Ambulance Response

Part III.
General Instruction: Please use the following scale in rating yourself. Kindly rate the extent which you experienced each aspect.
Check the box that is corresponding to your answer using the scale.

Legend: 4 - Strongly Agree 3 – Agree 2 – Disagree 1 - Strongly Disagree

Availability of Public Health Services (4) (3) (2) (1)

1. I am very satisfied with the local health care I receive.
2. I experience of getting prompt attention at receiving health services in the
last twelve (12) months.
3. It is easy for me to get medical care in an emergency.
4. If I need medical care I can get it without any trouble.
5. The office hours when I can get medical care is convenient for me.
6. I did not experience any significant delay on accessing treatment
intervention.
7. I did not experience any significant delay on accessing an appointment
with a specialist, (Doctor nurses, or other health experts).
8. It was easy to schedule an appointment in the local public health office.
9. I think the local public health facility in the municipality has everything
needed to provide complete medical care.
10. I did not experience any technical difficulties that might affect the quality
of care delivered by the healthcare provider.
Adequacy of Public Health Services (4) (3) (2) (1)
1.I am adequately informed by healthcare providers about my treatment
options
2. I am involved in decisions regarding my care by my healthcare providers
3. My healthcare providers give me the information I need about the safety of
my treatment
4. My healthcare provider adapts my care according to my changing needs
5. I receive good quality care according to the standard/ guidelines or best
practices available.
6. I am satisfied with the safety of care provided to me.
7. I am satisfied with continuity in my care over time.
8. The office staff, such as receptionists or clerks there, treats me with
respect.
9. My experience with physical examinations and treatments done in a way
that my privacy was respected.
10. The doctors, nurses or other health care providers, explain things in a
way that I could understand.