8/11/2019 Cht Survey Form

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8/11/2019 Cht Survey Form

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8/11/2019 Cht Survey Form

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As

CHT PARTNER SURVEY FORM

Please take our quick survey to assess your satisfaction with our CHT services.

We look forward to reviewing your responses. Please use a 4-point scale where 1 is Not

Satisfied 2 partially satisfied, 3 satisfied and 4 is Completely Satisfied.

1. Please rate your CHT services given to your assigned family.

1 2 3 4

1. Able to identify household memberWith health conditions/Risk.

2. Help the families with their health plans.

3. Refer to health provider for assistance.

4. Followup monitoring health planAdherence.

2. What are your contributions as a CHT partner that provides sustenance to fulfilthe health goals of your family?

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3. What are the benefits you get for being a CHT partner?

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4. Do you think that the CHT program should continue in giving services?

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Name:_____________________________ Position:__________________

Thank you for your time and feedback