IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

Inpatient Survey Regarding Laboratory Experience

Instructions: Use this tool when interviewing inpatients about their experience with laboratory
and/or diagnostic services.

Sections

A – Facility and Interviewer information (all respondents)

B – Based on medical record (all respondents)

C – Patient information (all respondents)

D – Laboratory testing during admission (all respondents)

E – Laboratory experience for patient who had tests at the lab in the health facility

F – Laboratory experience for patient who had tests at a public/ private laboratory outside the
health facility

G – Follow-up treatment and referral to specialists (all respondents)

Section A: Background information

(To be filled by interviewer)
A01 Respondent ID
A02 Country Ethiopia…………………………………………….1

A03 District/County *add list based on final sample*

A04 Date of interview (day/month/year)

A05 Facility ID code (site of recruitment) (List of facilities)

A06 Interviewer name and code

Section B: Information to be obtained from the patient chart or medical record and filled in by
the interviewer looking at the record provided by clinician

B01 Please note down the Questions B02-

Patient Medical B04 will be
Record ID ___________________ filled from the
(E)MR. Go to
C01
B02 Date of patient
admission
(day/month/year)

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

B03 Symptoms/Health Prevention/Screening…………………………………………………………..1

condition that
patient was admitted
for
(Circle all that apply)
Prenatal care………………………………………………………………………..2
Fatigue………………………………………………………………………………….3
Weight loss…………………………………………………………………………..4
Edema…………………………………………………………………………………..5
Chronic pain………………………………………………………………………….6
Rhinitis………………………………………………………………………………….7
Chest pain…………………………………………………………………………….8
Syncope………………………………………………………………………………..9
Rash…………………………………………………………………………………….10
Insomnia……………………………………………………………………………..11
Acute abdominal pain………………………………………………………….12
Chronic abdominal pain……………………………………………………….13
Nausea/Vomiting…………………………………………………………………14
Jaundice……………………………………………………………………………….15
GI bleeding…………………………………………………………………………..16
Acute Diarrhea……………………………………………………………………..17
Chronic diarrhea………………………………………………………………..18
Mass (tumor).…………………………………………………………………….19
Cough/dyspnea…………………………………………………………………….20
Hemoptysis…………………………………………………………………………..21
Fever…………………………………………………………………………………….22
Vaginal discharge (Sexually transmitted disease)…………………23
Hematuria……………………………………………………………………………24
Headache…………………………………………………………………………….25
Neurological dysfunction (stroke) ……………………………………….26
Seizure…………………………………………………………………………………27
Dizziness………………………………………………………………………………28
Tremor…………………………………………………………………………………29
Behavior change…………………………………………………………………..30
Muskuloskeletal pain……………………………………………………………31
Incontinence…………………………………………………………………………32
Amenorrhea………………………………………………………………………….33
Infertility……………………………………………………………………………….34
Sexual dysfunction………………………………………………………………..35
Vaginal bleeding……………………………………………………………………36
Malaria ……………………………………………………………………………….37
Hypertension……………………………………………………………………….38
Diabetes……………………………………………………………………………….39
Other (specify)………………..…………………………………………………….96

Health condition is illegible/unreadable…………………………..98

Health condition is missing……………………………………………….99
B04 List of all tests General Haematology
ordered during Hb……………………………………………………….……………………………….01
admission Full Blood Count…………………………………………………………………..02
(Circle all that apply) ESR……………………………………………………………………………………….03
Reticulocytes………………………………………………………………………..04
Sickling Test………………………………………………………………………….05
Bf For Malaria Parasite………………………………………………………….06
RDT for Malaria Parasite……………………………………………………….07

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

Widal Test…………………………………………………………………………….08
Special Haematology
Hb A2 & F…………………………………………………………………………….09
G6PD……………………………………………………………………………………10
Osmotic Fragility………………………………………………………………….11
Bone Marrow Trephine Biopsy…………………………………………….12
Bone Marrow Aspirate…………………………………………………………13
LE Cell Test…………………………………………………………………………..14
Blood Film Comment……………………………………………………………15
Hb Electrophoresis……………………………………………………………….16
Coagulation
Clotting profile……………………………………………………………………17
Prothrombin Time………………………………………………………………18
INR……………………………………………………………………………………..19
APTT……………………………………………………………………………………20
Clotting Time………………………………………………………………………21
Bleeding Time……………………………………………………………………..22
Thrombin Time……………………………………………………………………23
Fibrinogen…………………………………………………………………………..24
D-Diners………………………………………………………………………………25
Factor VIII Assay………………………………………………………………….26
Factor IX Assay……………………………………………………………………27
Serology
Blood Group………………………………………………………………………28
VDRL………………………………………………………………………………….29
HIV (1 & 2) ………………………………………………………………………..30
CD4……………………………………………………………………………………31
PCR – DBS (infant under 6 months)……………………………………32
PCR – Tuberculosis…………………………………………………………….33
HBsAg………………………………………………………………………………..34
Viral Load…………………………………………………………………………..35
HCV Antibodies…………………………………………………………………36
Hepatitis B profile……………………………………………………………..37
Rheumatoid Factor……………………………………………………………38
Other (specify)………………………………………………………………….96

Prescribed lab tests are missing………………………………………….99

Section C: Patient information

Instructions: Information collected from the patient or their caretaker/guardian.
C01 Is the patient the Yes………………………………….1 If
respondent? No………………………………….2 C01
is 1,
go
to
C03.

If
C01

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

is 2,
go
to
C02.

C02 Relationship of Parent……………………………………………….1

respondent to Spouse………………………………………………2
patient Caretaker………………………………………….3
Friend……………………………………………….4
Other (specify)…………………………………….96

C03 Patient gender Male…………………………………………….…..1

Female……………………………………………..2
Do not wish to identify………………….….3
C04 Patient age Years |__|__|
(If less than a year Months |__|__| (Only if <1 year old)
old, enter months)
C05 What is the (0) No schooling
highest level of (1) Primary
education you (the (2) Secondary 1 (1st cycle)
patient) has (3) Secondary 2 (2nd cycle)
completed? (4) Superior/Upper
Primary,
Secondary 1 (1st
cycle), Secondary
2 (2nd cycle) or
Superior?
C06 How long did you
(the patient) travel __________ hours
to reach this
facility today?
C07 Do you (does the Yes………………………..1 If 2
patient) have No…………………………2 or
coverage from the Don’t know…………….9 9,
national health skip
insurance scheme? to
C09
C08 Will this inpatient Yes, it will be fully covered ………………………..1
admission be Yes, it will be partially covered…………………………2
covered by a No, it will not be covered at all ...................3
national health Don’t know…………….9
insurance scheme?
C09 Do you have a Yes…………………………………………….……..1
below poverty line No…………………………………………………….2
card or
identification?
(Adapted for each
country)

C10 I would like to ask (Insert asset index list)

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

you a few
questions about
your household.
Which of the
following items do
you have in your
household?

Section D: Laboratory testing of inpatient

(Introduce to the patient by saying: “I would like to ask you some questions regarding all the
samples that you provided for laboratory testing during your admission to the hospital.”

If the respondent is not the patient, replace “you” in the questions that follow with the term
“patient”
D01 What samples Blood……………………………………………….1
did you submit Urine………………………………………………..2
for lab testing Stool…………………………………………………3
during Throat swab……………………………………..4
admission? Nasal swab……………………………………….5
(Circle all that Sputum…………………………………………….6
apply) Genital swab…………………………………….7
X ray…………………………………………………8
Other (specify)
……………………………………………….96

D02 Where were At the laboratory in this health facility……..1 If 1, say "I see you
these tests At a lab outside this facility………….2 have only used the in-
done? Both at the in-house facility and an outside house facility lab” =>
lab….3 go to Section E, then
Don’t know/Can’t remember………..9 Section G

If 2, say “I see you

have only used
outside labs” => go to
Section F, then Section
G

If 3, say “I see you

have used both the in-
house facility lab, and
outside labs” =>
Complete BOTH
Section E and Section
F, then Section G

If 9, say “Thank you

for your time.” => End
interview

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

Section E: Experience of patient with tests done at a lab within the health facility
(Please ask these questions when the patient has indicated that they visited the in-house
laboratory for some or all tests)
Please say “I would like to ask some questions about your experience with the lab within the
health facility to perform tests advised by the provider. If you used the in-house lab more than
once, please discuss your most recent experience visiting this lab.”

E01 Which samples did Blood……………………………………………….1

you submit for testing
at the in-house lab?
(Circle all that apply)
Urine………………………………………………..2
Stool…………………………………………………3
Throat swab……………………………………..4
Nasal swab……………………………………….5
Sputum…………………………………………….6
Genital swab…………………………………….7
X ray…………………………………………………8
Don’t Know………………………………………9
Other (specify)……………………………………………….96

E02 Did you personally Yes…………………………………………….……..1 If 2 or 3, go

visit the in-house lab?
No, the provider took my samples to the to E07
lab…………………………………………………….2
No, a friend or family member took my samples to
the lab…………………………………………………….3
Other (please specify)…………………………….96

E03 You said earlier that Yes…………………………………………….……..1 Enabled if

you had to provide a
stool/ urine sample at
the in-house lab, did
you have access to a
toilet on the premises
to collect the urine or
stool sample?
E04 Did you have access
to a toilet reserved
for your gender?
E05 How would you rate
the cleanliness of the
toilet facilities?
E06 Did the technician
provide you with a
sterile collection cup?
E07 Why did you choose
this lab?
(Circle all that apply)
No…………………………………………………….2 E03=2 or 3
If 2 go to
E07
Yes…………………………………………….……..1
No…………………………………………………….2
Good…………………………………………..…….1
Average……………………………….……………2
Poor………………………………………………….3
Yes…………………………………………….……..1
No…………………………………………………….2
Doctor/provider advice…………………………….1
Suggested by friend………………….……2
Good service…………………………….……3
Affordability……………………………….….4
Easy to reach…………………………...……5
Quick results……………………….………..6

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

Have had tests done here before….7

Reliable results……………………………….8
Only location the test or collection equipment
were available………………9
Other (specify)…………………………………………….96

E08 From the time you <1 hour………………………...............………1

arrived at the lab,
approximately how
long did it take for
laboratory personnel
to take your sample?
E09 After collecting the
specimens, did the
lab personnel inform
you when the results
would be available?
E10 Were you given an
option to receive the
results electronically
or by mobile phone?
E11 Did you pay for any of
the tests?
E12 How much money did
you pay in total for all
the tests?
E13 How did you pay for
the lab tests? (Circle
all that apply)
1 to 2 hours………………………............…..2
Over 2 hours…………………………………….3
Don’t know / Don’t remember …………9
Yes…………………………………………….……..1
No…………………………………………………….2
Don’t know / Don’t remember …………9
Yes…………………………………………….……..1
No…………………………………………………….2
Don’t know / Don’t remember …………9
Yes…………………………………………….……..1 If 2 or 9 go
No…………………………………………………….2 to E14
Don’t know / Don’t remember …………9
Ethiopian birr/ Ghanaian cedi/ Kenyan shilling/
(Circle the correct option)
Own savings/ income……………………….1
Borrowed from friends/ relatives……..2
Borrowed from money lender/ bank..3
Sold assets………………………………4
Self-help groups……………………………….5
Paid using insurance…………………………6
Other (specify)………………………………..96

Don’t Know……………………………………….9

E14 Do you have an Yes…………………………………………….……..1 If 2 or 3 go

itemized invoice for No…………………………………………………….2 to E16
the tests you have Did not receive an invoice……………….3
done today?
Do I have your Yes…………………………………………….……..1 If 2 go to
permission to take a No…………………………………………………….2 E16
picture of it or record
the costs listed on it?
(Please take a picture
of the invoice if
available)
E15. This section should be filled by the interviewer looking at the itemized costs to patient (after

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

insurance) from the invoice or receipt for all tests conducted at the in-house lab, if available. If
test was conducted but fee was waived, or test was free, then please enter zero.
Test name Cost to patient
General Haematology
Hb
Full Blood Count
ESR
Reticulocytes
Sickling Test
Bf for Malaria
Parasite
RDT for Malaria
Parasite
Widal Test
Special Haematology
Hb A2 & F
G6PD
Osmotic Fragility
Bone Marrow
Trephine Biopsy
Bone Marrow
Aspirate
LE Cell Test
Blood Film
Comment
Hb Electrophoresis
Coagulation
Clotting profile
Prothrombin Time
INR
APTT
Clotting Time
Bleeding Time
Thrombin Time
Fibrinogen
D-Diners
Factor VIII Assay
Factor IX Assay
Serology
Blood Group
VDRL
HIV (1&2)
CD4
PCR – DBS (infant
under 6 months)
PCR – Tuberculosis
HBsAg
Viral Load
HCV Antibodies
Hepatitis B profile

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

Rheumatoid Factor
Other (specify)
E16 Was the laboratory Yes…………………………………………….……..1 If 1 or 9 go
able to perform all No…………………………………………………….2 to E19
your tests today? Don’t know/Can’t
remember…………………………………...…9
E17 What were the Some tests or collection equipment were not
reason(s) all the tests available at the lab…………………………………………1
were not performed I could not afford some of the tests
on your visit to the in- ordered……………………………………….2
house lab? Would take too long to receive the
(Circle all correct results…………………………………………….3
options) Would take too long to collect the specimen in the
lab………………………..4
I did not think it was necessary…………….5
I did not trust the health provider’s
recommendation…………6
I have a sensitivity to needles……………7
Other (specify) …………………………………..96

E18 What did you do to Came back to the same lab on a different
complete the day……....…1
remaining tests Visited another lab..............................……….…..2
Planning to visit another lab but have not yet done
so......................................................................3
I did not do the tests………………….……...........…4
I sought a second opinion…...........................5
Don’t know………….………………….............…………9
Other (specify)…………………………………............96

E19 Have you obtained Yes, I have obtained the results…..1 If 2 or 9 3

the results of the Yes, I have obtained some but not all of the go to E21
tests performed in results….2
the in-house lab? No, I have not received results….3

E20 How did you obtain
the results of the
tests you performed
in the laboratory
about 1-2 week(s)
ago?
Picked up in person from the lab
…………………………………1
Results sent to my mobile phone……..2
Results sent only to doctor /
provider……………………………………………3
Don’t know / Don’t remember …………9
Other (specify)………………………………………………..96

E21 How did the Lab scheduled pick-up appointment on the same
laboratory let you day samples were collected……………………………1
know that the test Lab called and informed me when results were
results were ready to available……………………………………………………….2
be picked up? Went to the lab multiple times in person to check

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

whether the results were available…………………….3

Other (specify)………………………………………………..96
E22 I would like to ask you to rate your experience using this lab on a scale of 1 to 5 where (1)
is Very Poor and (5) is Excellent. Please rate the lab facility for the following questions
(1)Very (2)Poo (3)Fair (4)Good (5)Excellent (9)Don’t
poor r know
a. Opening hours of the
facility
b. Attitude of the
laboratory staff
c. Cleanliness of the
facility
d. The time you waited
from your arrival to
the lab to when you
finished providing all
necessary samples
e. How quickly the
results were made
available to patient
by the lab
f. Trust in the quality of
results provided by
the lab
g. Affordability (cost of
services, cost of
transport, other costs
related to accessing
services)
h. Accessibility (in terms
of distance,
availability of
transport)
i. Overall satisfaction
E23 Would you visit this Yes…………………………………………….……..1
laboratory again if you No…………………………………………………….2
needed more tests Don’t Know………………………………………9

Section F: Laboratory experience for patient who had tests done at a public/ private laboratory
outside the health facility
(Please introduce by saying: “I would like to ask you questions about your most recent visit to the
laboratory outside of this facility to perform tests advised by the provider. If you visited an outside
lab more than once, please discuss your most recent experience visiting this lab.”

F01 What was the name of _________________________________________

the outside lab that
you/your
representative visited?
F02 Was this a public or a Public
private lab? Private

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1
F03 Which samples did you
submit for testing at
the outside lab?
(Circle all that apply)
F04 Did you personally visit
an outside lab?
F05 You said earlier that
you had to provide a
stool/ urine sample at
the outside lab, did you
have access to a toilet
on the premises to
collect the urine or
stool sample?
F06 Did you have access to
a toilet reserved for
your gender?
F07 Did the technician
provide you with a
sterile collection cup?
F08 Why did you choose
this lab?
(Circle all that apply)
F09 How did you/your
representative travel to
the laboratory?
Don’t know
Blood……………………………………………….1
Urine………………………………………………..2
Stool…………………………………………………3
Throat swab……………………………………..4
Nasal swab……………………………………….5
Sputum…………………………………………….6
Genital swab…………………………………….7
X ray…………………………………………………8
Don’t Know………………………………………9
Other (specify)……………………………………………….96
Yes…………………………………………….……..1 If 2 or 3,
No, the provider took my samples to the go to F13
lab…………………………………………………….2
No, a friend or family member took my samples to
the lab…………………………………………………….3
Other (specify)……………………………………………….96
Yes…………………………………………….……..1 Enabled if
No…………………………………………………….2 F03 = 2 or 3
If 2 go to
F08
Yes…………………………………………….……..1
No…………………………………………………….2
Yes…………………………………………….……..1
No…………………………………………………….2
Doctor/provider advice…………………………….1
Suggested by friend………………….……2
Good service…………………………….……3
Affordability……………………………….….4
Easy to reach…………………………...……5
Quick results……………………….………..6
Have had tests done here before….7
Reliable results……………………………….8
Test or collection equipment were not available at
in-house lab………………9
Other (specify)…………………………………………….96
Walk……………………………….…1
Public transport………………………2
Taxi…………………………………..3
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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1
F10 Approximately how
much money did
you/your
representative spend
to travel to the
laboratory?
F11 From the time you
arrived at the lab,
approximately how
long did it take for
laboratory personnel to
take your sample?
F12 After collecting the
specimens, did the lab
personnel inform you
when the results would
be available?
F13 Were you given an
option to receive the
results electronically or
by mobile phone?
F14 Did you pay for any of
the tests?
F15 How much money did
you pay in total for all
the tests?
F16 How did you pay for
the lab tests? (Circle all
that apply)
F17 Do you have an
itemized invoice for the
tests you have done
today?
F18 Do I have your
Private car……………………………4
Ambulance or vehicle provided by hospital….5
Don’t Know/Can’t Remember…………………….9
Other (specify)…………………………………………..96
Ethiopian birr/ Ghanaian cedi/ Kenyan shilling
(Circle the correct option)
<1 hour………………………...............………1
1 to 2 hours………………………............…..2
Over 2 hours…………………………………….3
Don’t know / Don’t remember …………9
Yes…………………………………………….……..1
No…………………………………………………….2
Don’t know / Don’t remember …………9
Yes…………………………………………….……..1
No…………………………………………………….2
Don’t know / Don’t remember …………9
Yes…………………………………………….……..1 If 2 or 9
No…………………………………………………….2 go to F17
Don’t know / Don’t remember …………9
Ethiopian birr/ Ghanaian cedi/ Kenyan shilling/
(Circle the correct option)
Own savings/ income……………………….1
Borrowed from friends/ relatives……..2
Borrowed from money lender/ bank..3
Sold assets………………………………4
Self-help groups……………………………….5
Paid using insurance…………………………6
Other (specify)………………………………..96
Don’t Know……………………………………….9
Yes…………………………………………….……..1 If 2 or 3
No…………………………………………………….2 go to F20
Did not receive an invoice……………….3
Yes…………………………………………….……..1
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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

permission to take a No…………………………………………………….2

picture of it or record
the costs listed on it?
(Please take a picture
of the invoice if
available)
F19. This section should be filled by the interviewer looking at the itemized costs to patient (after
insurance) from the invoice or receipt from the outside lab, if available. If test was conducted but
fee was waived, or test was free, then please enter zero.
Test name Cost to patient
General Haematology
Hb
Full Blood Count
ESR
Reticulocytes
Sickling Test
Bf for Malaria Parasite
RDT for Malaria
Parasite
Widal Test
Special Haematology
Hb A2 & F
G6PD
Osmotic Fragility
Bone Marrow
Trephine Biopsy
Bone Marrow
Aspirate
LE Cell Test
Blood Film Comment
Hb Electrophoresis
Coagulation
Clotting profile
Prothrombin Time
INR
APTT
Clotting Time
Bleeding Time
Thrombin Time
Fibrinogen
D-Diners
Factor VIII Assay
Factor IX Assay
Serology
Blood Group
VDRL
HIV (1&2)
CD4
PCR – DBS (infant
under 6 months)

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

PCR – Tuberculosis
HBsAg
Viral Load
HCV Antibodies
Hepatitis B profile
Rheumatoid Factor
Other (specify)
F20 Was the laboratory Yes…………………………………………….……..1 If 1 or 9
able to perform all your No…………………………………………………….2 go to F23
tests today? Don’t know…………………………………...…9
F21 What were the Some tests or collection equipment were not
reason(s) all the tests available at the lab…………………………………………1
were not performed on I could not afford some of the tests
your visit to the lab? ordered……………………………………….2
(Circle all correct Would take too long to receive the
options) results…………………………………………….3
Would take too long to collect the specimen in the
lab………………………..4
I did not think it was necessary…………….5
I did not trust the health provider’s
recommendation…………6
I have a sensitivity to needles……………7
Other (specify) …………………………………..96

F22 What did you do to Came back to the same lab on a different day……....
complete the …1
remaining tests Visited another lab..............................……….…..2
Planning to visit another lab...............…...……..3
I did not do the tests………………….……...........…4
I sought a second opinion…...........................5
Don’t know………….………………….............…………9
Other (specify)…………………………………............96

F23 Have you obtained the Yes, I have obtained the results…..1 If 2 go to
results of the tests Yes, I have obtained some but not all of the F25
performed in the results….2
outside lab? No, I have not received results….3

F24 How did you obtain the
results of your tests?
Picked up in person from the lab
…………………………………1
Results sent to my mobile phone……..2
Results sent only to doctor /
provider……………………………………………3
Other (specify)………………………………………………..96

Don’t know / Don’t remember …………9

Other……………………………………………….96
F25 How did the laboratory Lab scheduled pick-up appointment on the same

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1

let you know that the day samples were collected

test results were ready Lab called and informed me when results were
to be picked up? available
Went to the lab multiple times in person to check
whether the results were available
Other (specify)………………………………………………..96
F26 I would like to ask you to rate your experience using this lab on a scale of 1 to 5 where (1)
is Very Poor and (5) is Excellent. Please rate the lab facility for the following questions
(1)Very (2)Poo (3)Fai (4)Goo (5)Excellen (9)Don’t
poor r r d t know
a. Access to this facility
(in terms of
distance/cost of
transport)
b. Opening hours of the
facility
c. Attitude of the
laboratory staff
d. Cleanliness of the
facility
e. The time you waited
from your arrival to the
lab to when you
finished providing all
necessary samples
f. How quickly the results
were made available to
the patient by the lab
g. Trust in the quality of
results provided by the
lab
h. Affordability (cost of
services, cost of
transport, other costs
related to accessing
services)
Accessibility (in terms
of distance, availability
of transport)
i. Overall satisfaction
F27 Would you visit this Yes…………………………………………….……..1
laboratory again if you No…………………………………………………….2
needed more tests Don’t Know………………………………………9

Section G: Follow-up treatment and referral to specialists

Now I would like to ask you a few questions about follow-up treatment you have received based
on the lab tests conducted. In this section, I would like you to respond based not just on the last
set of lab tests that you have done, but all of the lab tests since you were admitted to this
hospital.
G01 Has a doctor reviewed the Yes…………………………………………….……..1 If 1, skip
lab test results? No…………………………………………………….2 to G03.

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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1
G02 Why has the doctor not
reviewed the test results?
(circle all that apply)
G03 Did the doctor provide
you with a diagnosis?
G04 Did the doctor prescribe
new medication, change
your medication, or
provide some new order
(e.g., dietary or behavioral
change) based on your
results?
G05 Did the doctor refer you
to a specialist or other
provider based on your
results?
G06 Have you seen the
specialist or other
provider already?
G07 Did the specialist
recommend a new
treatment based on your
results (eg. new
medication, change your
medication, or
recommend surgery)?
G08 Did you begin any of the
new treatments
prescribed?
G09 Did you face any barriers
to starting treatment?
G10 If yes, what barriers did
you face to start
treatment?
Don’t know................................................9
If 9,G11
Too busy...................................................1 Skip to
My treatment was already prescribed......2 G11
Lab tests came back too late…………………..3
Don’t know................................................9
Other (specify)……………………………………….96
Yes………………………………………………….1
No………………………………………………….2
Don’t know………………………………..…9
Yes…………………………………………….……..1
No…………………………………………………….2
Don’t know………………………………..…9
Yes…………………………………………….……..1 If 2 or 9
No…………………………………………………….2 skip to
Don’t know………………………………..…9 G07
Yes…………………………………………………….1
No………………………………………………………2
Don’t Know………………………………………….9
Yes…………………………………………….……..1 If 2 or 9
No…………………………………………………….2 then G11
Don’t know………………………………..…9
Yes…………………………………………………….1
No………………………………………………………2
Don’t Know………………………………………….9
Yes……………………………………………………….1 If 2 or 9
No…………………………………………………………2 then G11
Don’t Know……………………………………………9
Treatment not available at local
pharmacy………….1
Facility opening hours not convenient……….…..
…2
Transport not available……………..…….….……3
Friend / Family advised not to proceed…..
……….4
Too expensive / can’t afford…………….……..5
Did not trust the health provider’s
recommendation…6
Did not think the treatment was necessary…7
Seeking a second opinion ………………………8
Other (specify)
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IRB18086-AHDP-InpatientSurvey-V1-2022Sept1
G11 Have the symptoms for
which you sought care
changed since you visited
the doctor on …..[insert
date of first interview]
Thank you for participating in our study. We are very grateful for your time and effort.
……………………………………………….96
Yes, it got resolved
…………………………………………..1
It improved, but treatment is needed to
manage
condition……………………………………………………..2
It did not get resolved/stayed the
same………………….3
Don’t know ……………………………………………….9
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