1. Questionnaire

Dear Patient and Family Members:

Our continuing goal at the Health and Human Services Agency is to provide our patients with the highest quality in-home services possible.

You can help us by taking a few minutes to complete this questionnaire. Your comments and suggestions will help us to improve our services for all our patients. Your personal observations are very important to us.

Thank you very much,
TB Program Staff

* 1. Please rate the service you received from our public health staff:

* 2. Please rate the transportation services you received:

* 3. Were you and your family kept informed about your treatment progress and involved in the planning of your care?

* 4. Did you have the same Nurse or Social Service Aide for most of your care?

* 5. Were you satisfied with the number of visits received?

* 6. Were the staff knowledgeable and able to teach you about TB disease and treatment?

* 7. Did the staff show you and your family respect and courtesy?

* 8. Did our staff have a professional attitude when helping you get the health services you needed?

* 9. What improvements would you suggest?

* 10. Please add any additional comments you would like to make. For example: Did you understand why we stopped services? What you liked most about our service, etc.