Exit Interview

Document Sample
Exit Interview Powered By Docstoc
					                                                       5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls cover 7/13/2011




Questionnaire number




                                      PANCEA
       UCSF / WB / INSP / Axios / Imperial College

                                 Exit Questionnaire
                                       2003
                   Name                                                                            Code
  Interviewer
  Translator
  Supervisor
  Data entry


  Facility name




  Interviewer:     Month   Day   Start time End time         Language             Survey completed?
  Interview date


  Data entry:      Month   Day            Supervisor:                 Month           Day         Initials
  Date entered                            Survey complete
                                          Data entry complete



  Notes:
5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls cover 7/13/2011
                                                                                                                                                   5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls Sec01 SW 7/13/2011

Section 1: Treatment - SW                                                     field type
1   How many years ago were you first contacted by an NGO staff member?        numeric
2   How many times have you been visited by an NGO staff in the last 12        numeric                   If 0, skip to last Q45
    months?
3   How many minutes did he/she spend with you during your last                numeric
4   Do you feel that was enough time?                                             Y/N
5   Were you treated politely by the staff during your last interaction?          Y/N

                                                                                   Y/N     1. None.
    Last time you met the NGO staff member, did you want any particular            Y/N     2. HIV education/counseling
6
    services? If yes - which?                                                      Y/N     3. Condoms
                                                                                   Y/N     4. Treatment for STI
                                                                                   Y/N     5. Vocational training
                                                                                   Y/N     6. HIV testing
                                                                                   Y/N     7. Other ______________
                                                                                   Y/N     8. Other ______________

    Note: Order of following sections parallels order of answers in q6.
7   Were you given any HIV education or counseling last time?                     Y/N                     If no, skip to Q 10
8   How long did education / counseling last? (minutes)                        numeric                                            Q9
9   Were you satisfied with this service? very / somewhat / not at all / NA      choice                                              very

10 Were you given any printed information last time?                               Y/N                                            somewhat
                                                                                                                                   not at all

11 Do you receive condoms last time?                                              Y/N                     If no, skip to Q 14        NA

12 How many did you receive?                                                   numeric
13 How much did you pay for them? (local currency)                             numeric


14 Were you assisted in getting STI treatment last time?                           Y/N                    If no, skip to Q 19     Q16
15 Were you prescribed or recommended medicines for STI?                           Y/N                    If no, skip to Q 18     NGO
   If yes, did you receive the medicines from the NGO or from somewhere          choice                                           somewhere else
16
   else? NGO / somewhere else / NA                                                                                                NA
17 Did you pay for the medicines you received? Yes / Partly / No / NA            choice                                           Q17
18 Were you satisfied with this service? very / somewhat / not at all / NA       choice                                           Yes
                                                                                                                                  Partly
19 Were you given any vocational training last time?                              Y/N                     If no, skip to Q 22     No
20 How long did the vocational training last?                                  numeric                                            NA
21 Were you satisfied with this training? Very / somewhat / not at all / NA     choice
     Were you satisfied with the duration of this training? Very /
21                                                                               choice
     somewhat / not at all / NA
     Were you satisfied with the content of this training? Very /
21                                                                               choice
     somewhat / not at all / NA

22 Was blood drawn or any other sample taken last time?                            Y/N                    If no, skip to Q 24


                                                                                               3 of 10                                                      Sec01 SW 5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls
                                                                                                                                                                5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls Sec01 SW 7/13/2011

23 Do you know what for?                                                           Y/N/NA
24 Were you referred or taken for any tests last time you met an NGO staff            Y/N                   If no, skip to Q 32
                                                                                                                                           Q29
   member?
25 Do you know what for?                                                           Y/N/NA                                                  1 Same day
                                                                                                                                           2 Next day
26 Were you assisted in getting an HIV test last time?                                Y/N                                                  3 Two days later
27 Did you ever get an HIV test with the help of the NGO?                             Y/N                   If no, skip to Q 32            4 Within the same week
28 If yes: How long ago? (weeks)                                                   numeric                                                 5 Next week
                                                                                                                                           6 Sometime later
                                                                                                                                           7 Other _______________
                                                                                    choice                                                 8 Did not receive results
29 If yes, when did you receive the results? (see answers to right)
                                                                                                                                           NA
                                                                                                                                                     1. None
                                                                                                                                                Q31 2. They provided pre test counseling
30 Did you get any help from the NGO for your HIV testing?                            Y/N                    If no, go to Q32        N/A            3. Arranged for HIV testing
   If yes, what help did you get from the NGO staff for your HIV testing?
31                                                                                  choice
   (see answers to right)                                                                                                                            4. Provided post-test counseling
                                                                                                                                                     5. Advised about treatment options
32 Did you pay for the service(s) you received last time?                             Y/N                  If no, go to Q 34                         6. Other (specify) ________
33 How much did you pay?                                                           numeric                 Go to Q35                       Q34       NA
                                                                                                                                     N/A1. I will pay later
                                                                                                                                        2. Couldn't afford it
                                                                                    choice                                              3. I get free care
34 If you did not pay, why not? (see answers to right)
                                                                                                                                        4. Service is free to all
                                                                                                                                        5. Other specify
     Did you give any extra money or any gift other than the official fee to the
35                                                                                    Y/N                    If no, go to Q39
     service provider?                                                                                                                     NA

36 Did you give it in cash or in kind? Cash / kind / both / NA                      choice                 If in kind, go to Q38
                                                                                                                                           Q36
37 How much money did you give?                                                    numeric                 If no in-kind, go to 39         Cash
38 Can you estimate the value of the gift?                                         numeric                                                 Kind
                                                                                                                                           Both
     If one service was provided in last visit, indicate which and use as basis
     for questions 39 - 44. If more than one service was provided, select a           text
     service not addressed with other respondents.                                                                                         NA


     How many other service providers do you know where you could go to
39
     receive the services you received last time?
                                                                                   numeric                                                 Q40
                                                                                                                                           1. Clinic
For the nearest four other places:                                                           1   2             3           4               2. Shop
    What type of place are the other     1 Clinic            4 Mobile van                                                                  3. Hospital
40 service providers? (write the type in 2 Shop              5 Other (specify)      choice                                                 4. Mobile van
    the box)                             3 Hospital                                                                                        5. Other (specify)
                                                                                   numeric                                                 6. NA
41 How long does it take for you to get there from your home (minutes)?

                                                                                                 4 of 10                                                                 Sec01 SW 5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls
                                                                                                                                            5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls Sec01 SW 7/13/2011
41 How long does it take for you to get there from your home (minutes)?

42 Have you ever visited this service provider?                                   Y/N

     For the service you received here today, would you pay less, the same, or                                                   Q43
43
     more with this service provider?                                            choice                                          Less
                                                                                                                                 The same
                                                                                                                                 More
                                                                                  Y/N     1 Follow-up visit                      NA
   Why did you prefer to interact with staff members of this NGO rather           Y/N     2 Have been here before
44
   than one of the other facilities mentioned? (circle all that apply)            Y/N     3 Like the provider
                                                                                  Y/N     4 Closer to home
                                                                                  Y/N     5 Lower price
                                                                                  Y/N     6 Better quality
                                                                                  Y/N     7 Other ______________
                                                                                  Y/N     8 NA

   Ask Q 45 only of SWs who have not received services of this NGO in past 12 months.
45 Are you familiar with this NGO and the services it provides?             Y/N                         If no, go to Sec02


46 Overall, how well do you think this NGO serves the needs of clients like      choice                   Go to Sec02
                                                                                                                      very

                                                                                                                   somewhat
                                                                                                                    not at all
                                                                                                                      NA




                                                                                              5 of 10                                                Sec01 SW 5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls
Section 1: Treatment - Clinic-based                                        field type
1   Is this your first visit to this facility?                                  Y/N
2   How many times have you visited this facility in the past 12 months?    numeric

3   How many minutes did you spend waiting?                                 numeric
4   Do you feel that was too long?                                             Y/N
5   Were you treated politely while waiting?                                   Y/N

6   How long was your consultation with the provider?                       numeric
7   Do you feel that was enough time?                                          Y/N
8   Were you treated politely by the provider?                                 Y/N

                                                                                Y/N                  1. Follow up
                                                                                Y/N                  2. HIV education/counseling
9   Why did you visit this facility today? (note all that apply)
                                                                                Y/N                  3. Condoms
                                                                                Y/N                  4. Needles or syringes
                                                                                Y/N                  5. Treatment for STI
                                                                                Y/N                  6. HIV testing
                                                                                Y/N                  7. Family planning
                                                                                Y/N                  8. Antenatal care
                                                                                Y/N                  9. Other ______________

   Note: Order of following sections parallels order of answers in q 9.
10 Were you given any HIV education or counseling?                             Y/N                                 If no, skip to Q 13                Q12
11 How long did education / counseling last? (minutes)                      numeric                                                                       very

12 Were you satisfied with this service? very / somewhat / not at all /       choice                                                                   somewhat

13 NA you given any printed information?
   Were                                                                         Y/N                                                                    not at all
                                                                                                                                                          NA

14 Do you receive condoms?                                                     Y/N                                 If no, skip to Q 17
15 How many did you receive?                                                numeric
16 How much did you pay for them? (local currency)                          numeric


17 Did you receive syringes, needles, or bleach today?                          Y/N                               If no, go to Q 20

                                                                                    syringes/needlesbleach kits
18 How many did you receive?                                                numeric

19 How much did you pay for them?                                           numeric


                                                                                           6 of 10                                       Sec01 Clinic-based 5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls
20 Did you receive STI treatment?                                                 Y/N               If no, skip to Q 25                Q22
21 Were you prescribed or recommended medicines for STI?                          Y/N               If no, skip to Q 24                Clinic
   If yes, did you receive the medicines from the clinic or do you have to      choice                                                 somewhere else
22
   go somewhere else? clinic / somewhere else / NA                                                                           Q23       NA
23 Did you pay for the medicines you received? Yes / Partly / No / NA           choice                                       Yes
24 Were you satisfied with this service? very / somewhat / not at all /         choice                                       Partly    Q26
   NA
                                                                                                                             No        1 Today / already received
                                                                                                                             NA        2 Tomorrow
25 Did you get an HIV test?                                                       Y/N               If no, skip to Q 27                3 Two days later
                                                                                                                                       4 Within the same week
26 If yes, when will you receive the results? (see answers to right)            choice                                                 5 Next week
                                                                                                                                       6 Sometime later
                                                                                                                                       7 Other _______________
                                                                                                                                       NA
27   Were any other tests conducted today?                                        Y/N              If no, go to Q 28
28   Do you know what for?                                                        Y/N
29   Was blood drawn or any other sample taken?                                   Y/N              If no, go to Q 32
30   Do you know what for?                                                        Y/N
31   (no question 31)                                                                                                                  Q34
32   Did you pay for the service(s) you received?                                 Y/N              If no, go to Q 34                   1. I will pay later
33 How much did you pay?                                                       numeric             Go to Q35                 N/A       2. Couldn't afford it
                                                                                                                                       3. I get free care
                                                                                                                                       4. Service is free to all
34 If you did not pay, why not? (see answers to right)                          choice                                                 5. Other specify
                                                                                                                                       NA
     Did you give any extra money or any gift other than the official fee to
35                                                                                Y/N                 If no, go to Q39
     the service provider?                                                                                                             Q36
36 Did you give it in cash or in kind? Cash / kind / both / NA                  choice              If in kind, go to Q38              Cash
37 How much money did you give?                                                numeric             If no in-kind, go to 39             Kind
38 Can you estimate the value of the gift?                                     numeric                                                 Both
                                                                                                                                       NA
     If one service was provided in last visit, indicate which and use as
     basis for questions 39 - 44. If more than one service was provided,          text
     select a service not addressed with other respondents.                                                                            Q40
                                                                                                                                       1. Clinic
     How many other service providers do you know where you could go
39                                                                             numeric                                                 2. Shop
     to receive the services you received last time?

                                                                                         7 of 10                          Sec01 Clinic-based 5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls
     How many other service providers do you know where you could go
39
     to receive the services you received last time?
                                                                                                                                              3. Hospital
For the nearest four other places:                                                       1              2          3         4                4. Mobile van
   What type of place are the other      1 Clinic          4 Mobile van                                                                       5. Other (specify)
40 service providers? (write the type in 2 Shop            5 Other (specify)    choice                                                        6. NA
   the box)                              3 Hospital
                                                                               numeric
41 How long does it take for you to get there from your home (minutes)?

42 Have you ever visited this service provider?                                   Y/N
                                                                                                                                              Q43
                                                                                                                                              Less
     For the service you received here today, would you pay less, the
43                                                                              choice                                                        The same
     same, or more with this service provider?
                                                                                                                                              More
                                                                                                                                              NA
                                                                                  Y/N              1 Follow-up visit
   Why did you prefer to use this clinic rather than one of the other             Y/N              2 Have been here before
44
   facilities mentioned? (circle all that apply)                                  Y/N              3 Like the provider
                                                                                  Y/N              4 Closer to home
                                                                                  Y/N              5 Lower price
                                                                                  Y/N              6 Better quality
                                                                                  Y/N              7 Other ______________
                                                                                  Y/N              8 NA

45 (no question 45)                                                                                                                           Q46
                                                                                                                                                  very
   Overall, how well do you think this clinic serves the needs of clients                                          Go to Sec02
46                                                                              choice                                                         somewhat
   like you? Very / somewhat / not at all
                                                                                                                                               not at all
                                                                                                                                                  NA




                                                                                         8 of 10                                 Sec01 Clinic-based 5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls
                                                                                                                                                             5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls Sec02 pers info 7/13/2011



Section 2: Personal information                                     field type
     How far did you come to see this service provider today (or        choice            <0.1                  <1             3-5          10-20           1-2               5-10                >20
 47
     the last time you got services)? (km)
     How long did it take you to get here today (or the last time      choice              <1                  <10            30-60        120-180         10-30            60-120               >180
48
     you got services)? (minutes)
   How did you get here today (or the last time you got                                                                                                 5 Hired car /                          7 Other
49                                                                     choice            1 Walk             2 Bicycle      3 Motor-bike 4 Bus / train                     6 Own car
   services)? (see answers to right)                                                                                                                        taxi                              (specify)
   How much did you pay to get here today (or the last time
50                                                                   numeric
   you got services)?

51 Interviewer - Note sex of respondent                                  M/F

52 How old are you? (circle one)                                       choice             <25                 26-30           31-35        36-40        41-45               46-50               51-55               56-60         >60
                                                                                                                                        4 Divorced /                    6 Other
53 What is your marriage status? (circle one)                          choice         1 Single             2 Cohabiting 3 Married                    5 Widowed
                                                                                                                                        separated                       (specify)
54 How many children do you have? (circle one)                         choice               0                  1-2             3-5           >5
55 (for women) How many children have you ever borne?                  choice               0                  1-2             3-5           >5
   (circle one)

56 What is the highest level of schooling you achieved? (circle        choice         1 None               2 Primary       3 Secondary 4 Preparatory 5 University
   one)

57 What is your personal monthly income?                             numeric

                                                                                                                             3. Move
                                                                                        1. Family          2. With other                  4. Other
58 Where do you currently stay?                                        choice                                                between
                                                                                        household              SWs                        (specify)
                                                                                                                             1 and 2.
59 How long have you had this living situation? (months)             numeric


     The following questions pertain to the SW respondent's family's household.
60 How many people live in your household, in total?                 numeric

61 How many of these people are working?                             numeric

62 How many children (<= 15) live in your household?                 numeric

63 How many of these children are usually in school?                 numeric


     What is the estimated monthly income of the other working
64                                                                   numeric
     members of your household?


                                                                         Y/N      Bicycle
     Does anyone in your household own any of the following
65                                                                       Y/N      Motorbike
     items? (circle answer)
                                                                         Y/N      Car
                                                                         Y/N      Sewing machine
                                                                         Y/N      Television

                                                                                                 9 of 10                                                              Sec02 pers info 5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls
                                                                                                                                                  5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls Sec02 pers info 7/13/2011



                                                                     Y/N    Radio / stereo
                                                                     Y/N    Refrigerator
                                                                     Y/N    Gas / electric stove
                                                                     Y/N    Washing machine
                                                                     Y/N    Computer

66 Does your household have electricity?                             Y/N
67 Does your household have piped water?                             Y/N

   What is the highest level of schooling your mother
68                                                                 choice        1 None               2 Primary   3 Secondary 4 Preparatory 5 University
   achieved? (see answers to right)
   What is the highest level of schooling your father achieved?
69                                                                 choice
   (see answers to right)

70 Do you have brothers or sisters in the area?                   numeric




                                                                                           10 of 10                                                        Sec02 pers info 5c7eedfb-1dde-472d-9bab-ad3184eaa210.xls

				
DOCUMENT INFO