Evaluation: Sample Forms

Evaluation Instrument Examples

In the sections that follow, two evaluation instrument examples are presented, including those for use at the patient and staff levels.

Sample Patient Survey

This instrument could be used for assessment of patients' perception of delivery of care and satisfaction with care. It should be given to the patient at the end of a patient's visit to the clinic. The brief, anonymous questionnaire should take no more than 5 minutes to complete. (See Sample Patient Survey as Appendix A)

Clinic Staff Survey

This module consists of two components: (1) session evaluation and (2) program impact on staff's role, responsibilities, and functions. The first questionnaire can be administered at the end of each session of the CMHA program training, while the second can be given to staff following the implementation of the CMHA program. Both anonymous forms should take no more than 5 minutes to complete. (See Sample Staff Survey as Appendix B)

Clinic Management Information Gathering

The purpose of this activity is to allow clinic managers to assess how the CMHA program has affected continuity-of-care aspects of the clinic and how often program impact should be evaluated.

Records Abstraction

This set of activities consists of examining clinic records (e.g., medical records) to obtain relevant impact information that can provide useful information about the clinic's performance following the implementation of the CMHA program. The data abstracted could include patient visit information, types of ancillary services used, other treatment information, etc.

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Appendix A - Sample Patient Survey

Your opinion of the Creating a Medical Home for Asthma program is very important to us. It will help us understand how we are doing in helping to (1) treat your child's asthma and (2) work with you to better manage your child's asthma condition. We will also get important information from you about how we can improve the Creating a Medical Home for Asthma program.

Please circle the number (for example, ) that best fits your answer for each question.
					Yes	No
1.	Is this your first visit to this clinic?
					1	2
For this visit, did you have any problems with the following:
			(Circle one number for each question )
				Yes	No	If yes, please comment
2	Scheduling the visit			1	2
3.	Getting to the clinic			1	2
4.	Waiting to see your child's doctor			1	2
5.	Seeing and talking with your child's doctor			1	2
6.	Getting an appointment for an asthma specialist			1	2

For this visit, how satisfied were you with the following:
			(Circle one number for each question)
			Very dissatisfied	Dissatisfied	Neutral- Neither satisfied_nor dissatisfied	Satisfied	Very Satisfied	Not applicable
7.	Helpfulness of the clinic staff		1	2	3	4	5	NA
8.	Helpfulness of the doctor		1	2	3	4	5	NA
9.	Helpfulness of the advice from an asthma specialist		1	2	3	4	5	NA
10.	The overall visit		1	2	3	4	5	NA

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Appendix B - Sample Staff Survey - Session Evaluation

Your opinion of this session of the Creating a Medical Home for Asthma program is very important to us. Your honest feedback will help us continue to improve the program. Thank you for your participation.

Trainer:

_____________

Today's Date:

__________

1. Please rate the TRAINER on the following: (Circle one number in each row)
	Trainer
				Poor				Excellent
a.	Subject knowledge			1	2	3	4	5
b.	Preparedness			1	2	3	4	5
c.	Communication skills			1	2	3	4	5
d.	Responsiveness to questions and concerns			1	2	3	4	5
e.	Overall rating			1	2	3	4	5

Comments:_____________________________________________________________________
______________________________________________________________________________

2. Please rate the SESSION on the following: (Circle one number in each row)
	Program
				Poor				Excellent
a.	Content			1	2	3	4	5
b.	Materials			1	2	3	4	5
c.	Helpfulness			1	2	3	4	5
d.	Length			1	2	3	4	5
e.	Overall rating			1	2	3	4	5

Comments:_____________________________________________________________________
______________________________________________________________________________

3. What other comments or suggestions do you have about this session?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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