Download - 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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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