Building Your Medical Home:
An Introduction to Pediatric Primary Care Transformation
User Evaluation Survey

Question Title

* 1. Please indicate the profession that best describes you.

Family Member/Advocate

Health Provider/Professional

Education Provider/Professional

State Maternal and Child Health Agency staff

Community-Based/Local Organization staff

Other (please specify)

Question Title

* 2. Overall, how useful did you find the "Building Your Medical Home" resource?

Not at all useful

Somewhat useful

Very useful

Why? (please specify)

Question Title

* 3. What was the most useful component of the "Building Your Medical Home" resource?

Form a Medical Home Improvement Team

Assess Your Practice

Understand Quality Improvement

Family Centered Care

Coordinated Care

Manage Your Patient Population

Sustain Your Medical Home

Why? (please specify)

Question Title

* 4. What was the least useful component of the "Building Your Medical Home" resource?

Form a Medical Home Improvement Team

Assess Your Practice

Understand Quality Improvement

Family-Centered Care

Coordinated Care

Manage Your Patient Population

Sustain Your Medical Home

Why? (please specify)

Question Title

* 5. Do you have any additional comments about the "Building Your Medical Home" resource?

Question Title

* 6. May we contact you in the future for evaluation purposes?

Yes

No

If yes, please provide your contact information: