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This is the questionnaire that deals with health care and your involvement in health care. Please take a few minutes to express your opinions about the availability and quality of health care in your community. Your answers are important to the success of this study.
Thank you for your assistance. |
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| Which community (or rural area) do you live? | | |
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| Do you have a favorite hospital? |
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| Do you receive considerable amount of pressure from other family members to get health care problems taken care of promptly? |
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| Do you generally receive care from the same hospital? |
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| How many years have you lived in this community? | | |
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| Convenience of location for you |
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| What kind of medical insurance coverage do you have? |
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| How many times have you visited a friend or loved one in the hospital in the last year? | | |
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| How many times have you and other members of your family been a patient in a hospital in the last 3 years? | | |
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| Which source of care would you prefer if you had a personal injury that could be handled equally well by each of these sources of health care: |
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| When making health care decisions for your family, who is the primary decision maker? |
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| From your experience in the past, when you or a member of your family needs hospital care, who decides on the hospital? |
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| The last section of the questionnaire contains a series of questions about your demographic characteristics such as age and income. We are asking these questions in order to determine if various groups have different opinions and attitudes about hospital care. Please answer these personal questions. No one will ever associate these responses with your name. |
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| Sex of person completing this questionnaire: |
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| Age of person completing this questionnaire: | | |
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| Age(s) of children living in your household: (Check all that apply) |
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| Marital status of person completing this questionnaire: |
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| What was your total household income (from all sources) before taxes for the year [Year]? |
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| Please indicate the highest level of formal education that you have completed. |
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| What is your primary occupation? | | |
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| What is your spouse's primary occupation? | | |
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| When making health care decisions for your family, who is the primary decision maker? |
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