Health Care Opinion Survey Is there a wide difference in performance between the available hospitals in this area? Yes No Not sure Do you have a favorite hospital? Yes No Do you receive considerable amount of pressure from other family members to get health care problems taken care of promptly? Yes No Only sometimes Do you feel comfortable judging the differences between hospitals in this area? Yes No Not sure Do you generally receive care from the same hospital? Yes No Not sure Can you be helpful to friends who are having difficulty making section of a hospital? Yes No Not sure How many years have you lived in this community? How satisfied are you with the skill and competency of the staff? Very satisfied Somewhat satisfied Neutral Somewhat dissatisfied Very dissatisfied Not sure Does the hospital have equipment for modern diagnosis and treatment? Yes No Not sure How satisfied are you with the following: Overall cleanliness of the hospital Very satisfied Somewhat satisfied Neutral Somewhat dissatisfied Very dissatisfied Not sure Efficiency of nursing care Very satisfied Somewhat satisfied Neutral Somewhat dissatisfied Very dissatisfied Not sure Friendliness and courtesy of the staff Very satisfied Somewhat satisfied Neutral Somewhat dissatisfied Very dissatisfied Not sure Convenience of location for you Very satisfied Somewhat satisfied Neutral Somewhat dissatisfied Very dissatisfied Not sure How many times have you and any member of your family been to your doctor in the last year? How many times have you visited a friend or loved one in the hospital in the last year? How many times have you and other members of your family been a patient in a hospital in the last 3 years? 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: I would prefer to go to a walk-in clinic I would prefer to go to my personal physician I would prefer to go to the hospital emergency room Other If you or a member of your family have received medical care at another hospital while living in the [HOSPITAL] area, why did you choose the other hospital? A specialist was available Special hospital care was required that was not available in the local area My physician practices there More familiar with that hospital Wanted a second opinion from another physician Religious preference Cost was too high in the local area Other When making health care decisions for your family, who is the primary decision maker? Male Female Jointly From your experience in the past, when you or a member of your family needs hospital care, who decides on the hospital? You usually decide You decide based on information from your physician You and your physician decide together Your physician decides based on information you provide Your physician decides Depends on the situation What have you heard about the care patients receive at [Hospital]? 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. Sex of person completing this questionnaire: Male Female Age of person completing this questionnaire: Age(s) of children living in your household: (Check all that apply) < 12 12 - 18 18+