Form Survey Questions

 

  1. Do you think this household follow-up form addresses on the most important health issues facing the community?
    1. Yes
    2. No

 

  1. What do you think about the length of the household follow-up form?
    1. I think this form is too long .
    2. I think this form is the right length.
    3. I think this form is too short .

 

  1. How often do you ask the client every question displayed in the household follow-up form during household visits?
    1. I always ask the client every question in the form.
    2. I sometimes ask the client every question in the form.
    3. I never ask the client every question in the form.

 

  1. Do you think there are questions on the household follow-up form that don’t need to be asked during every household visit?
    1. Yes, can you please list (just mention the topic): _________________________________________________________________
    2. No

 

  1. Do you think there are some questions in the household follow-up form that are too personal to ask?
    1. Yes, can you please list (just mention the topic): _________________________________________________________________
    2. No

 

  1. How effective are the current educational messages (one example is the educational message around the importance of immunizing children) in the household follow-up form at educating your clients and their families?
    1. I think the current education messages are very effective at educating my clients and their families.
    2. I think the current education messages are a little effective at educating my clients and their families.
    3. I think the current education messages at not effective at educating my clients and their families.

 

The following section will ask you how “strongly” you feel about each sentence describing the questions on the form.  You will have 5 options to mark for how strongly feel.  Please mark the option which most accurately describes how you feel. 

How do you feel about the questions in the household follow-up form?

 

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

7. I feel every question is important.

8. I feel every question needs to be asked during every client visit.

9. I feel there are too many questions.

10. I feel some questions are too personal.

11. I feel the current educational messages are useful for educating my clients.

12. I feel that the form addresses the most important health issues in the community.