Tab 3
CLINIC STAFF SURVEY
As part of the Stay Connected project, all clinic staff with any patient contact are being asked to complete a very brief survey periodically. Your participation on this survey is voluntary. Your consent to participate is implied by completing and returning this survey.
Your name will not appear on this survey but we will ask you to provide the last two digits of your social security number and the month you were born as a means of linking your surveys across time.
If you decide to participate, please seal your completed survey in the attached envelope and return to the study coordinator (name of person).
Last two digits of your social security number: _____ _____
Month of your birth (check one):
January July
February August
March September
April October
May November
June December
1. Today’s Date: ___ ___/___ ___/___ ___ ___ ___ (MM/DD/YYYY)
2. Study Site
Alabama-Birmingham Johns Hopkins
Boston Miami
Houston/Thomas St. SUNY Brooklyn
3. What type of clinic staff are you?
Nurse Pharmacist
Social worker/case manager Laboratory or medical
Mental health professional assistant
Receptionist/front desk
Other, please specify: ____________________________________________
4. What is your sex?
Female
Male
5. Think of the patients you came into contact with during the most recent day you were at this clinic. How many of these patients did you talk to about the importance of keeping clinic appointments?
Every patient (100%)
Almost every patient (80- 99%)
More than half of the patients (60-79%)
About half of the patients (40-59%)
Fewer than half of the patients (20-39%)
Very few patients (1-19%)
No patients (0%)
6. Compared to before the Stay Connected project started, how much are you talking to patients about the importance of keeping clinic appointments?
Much less than before
Somewhat less than before
About the same as before
Somewhat more than before
Much more than before
7. Compared to before the Stay Connected project started, how much attention is the clinic giving to the importance of patients keeping clinic appointments?
Much less than before
Somewhat less than before
About the same as before
Somewhat more than before
Much more than before
| File Type | application/msword |
| File Title | TAB 1 |
| Author | Faye Malitz |
| Last Modified By | HRSA |
| File Modified | 2009-07-16 |
| File Created | 2009-06-30 |