2024 Respiratory Virus Immunization Clinic

Client Experience Questionnaire

Tell us about your experience! Your feedback helps us to improve the way we provide care. This questionnaire was built upon our Patient Values (Dignity, Respect and Trust, Information Sharing, Participation, Accessibility and Responsiveness and Quality).

We do not collect personal information unless you request a follow-up.

If the question does not apply, please leave blank.

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* Dignity, Respect and Trust:
(If question does not apply, leave blank)

	Strongly Agree	Agree	Disagree	Strongly Disagree
a. My privacy was respected as best it could be.	a. My privacy was respected as best it could be. Strongly Agree	a. My privacy was respected as best it could be. Agree	a. My privacy was respected as best it could be. Disagree	a. My privacy was respected as best it could be. Strongly Disagree

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* Information Sharing:
(If question does not apply, leave blank)

	Always	Usually	Sometimes	Never
a. My healthcare provider used words I could understand.	a. My healthcare provider used words I could understand. Always	a. My healthcare provider used words I could understand. Usually	a. My healthcare provider used words I could understand. Sometimes	a. My healthcare provider used words I could understand. Never

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* Participation:
(If question does not apply, leave blank)

	Always	Usually	Sometimes	Never
a. My choices were respected.	a. My choices were respected. Always	a. My choices were respected. Usually	a. My choices were respected. Sometimes	a. My choices were respected. Never

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* Accessibility and Responsiveness:
(If question does not apply, leave blank)

	Strongly Agree	Agree	Disagree	Strongly Disagree
a. I had access to the care I needed.	a. I had access to the care I needed. Strongly Agree	a. I had access to the care I needed. Agree	a. I had access to the care I needed. Disagree	a. I had access to the care I needed. Strongly Disagree

Question Title

* Quality:
(If question does not apply, leave blank)

	Always	Usually	Sometimes	Never
a. I saw the healthcare provider(s) clean their hands before providing my care.	a. I saw the healthcare provider(s) clean their hands before providing my care. Always	a. I saw the healthcare provider(s) clean their hands before providing my care. Usually	a. I saw the healthcare provider(s) clean their hands before providing my care. Sometimes	a. I saw the healthcare provider(s) clean their hands before providing my care. Never
b. My identity was confirmed before receiving care. (e.g. confirmed my name, checked my MB Health card)	b. My identity was confirmed before receiving care. (e.g. confirmed my name, checked my MB Health card) Always	b. My identity was confirmed before receiving care. (e.g. confirmed my name, checked my MB Health card) Usually	b. My identity was confirmed before receiving care. (e.g. confirmed my name, checked my MB Health card) Sometimes	b. My identity was confirmed before receiving care. (e.g. confirmed my name, checked my MB Health card) Never

Question Title

* Quality:
(If question does not apply, leave blank)

	Strongly Agree	Agree	Disagree	Strongly Disagree
c. Overall, I was satisfied with the quality of care I received.	c. Overall, I was satisfied with the quality of care I received. Strongly Agree	c. Overall, I was satisfied with the quality of care I received. Agree	c. Overall, I was satisfied with the quality of care I received. Disagree	c. Overall, I was satisfied with the quality of care I received. Strongly Disagree

Question Title

* a. How did you learn about the Respiratory Virus Immunization Clinic?
(Check all that apply)

Poster

Website

Newspaper

Access TV

Radio

Social Media

Health Care Provider

Other (please specify)

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* b. In which community did you attend a Respiratory Virus Immunization Clinic?

Demographics: (of the patient) Collected for statistical purposes only to target improvements.

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* Gender:

Male

Female

Gender Diverse

Prefer not to answer

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* Ethnicity (Race):

Caucasian (White)

Indigenous (First Nations, Inuit, Metis)

Black

Asian (South, East)

Chinese

Filipino

Japanese

Korean

Latin American

Middle Eastern

Prefer not to answer

Other (please specify)

Question Title

* Age:

0-4 years

5-9 years

10-14 years

15-19 years

20-24 years

25-29 years

30-34 years

35-39 years

40-44 years

45-49 years

50-54 years

55-59 years

60-64 years

65-69 years

70-74 years

75-79 years

80-84 years

85-89 years

90 years and older

Question Title

* Comments:

Respiratory Virus Immunization Clinic Patient Partner Volunteers Needed!!
Someone just like you helped to design this survey!

We want to partner with existing Respiratory Virus Immunization Clinic patients or family members who might be interested in helping us review, design or provide feedback to our services. By leaving your name, phone number and email address below, you are indicating your interest in partnering with Prairie Mountain Health (PMH) and are consenting to be contacted by Patient Relations. Patient Relations will be in contact with you when an opportunity becomes available.

Question Title

* Volunteer Contact Information:

Volunteer Full Name:

Home Community:

Phone Number:

Email Address:

Forward additional concerns or compliments regarding your care to Patient Relations.
Patient Relations: email patientrelations@pmh-mb.ca or call 1-800-735-6596

Questions or concerns related to this survey can be sent to ceq@pmh-mb.ca

Thank you for your participation!

Question Title

* Dignity, Respect and Trust:(If question does not apply, leave blank)

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* Information Sharing:(If question does not apply, leave blank)

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* Participation:(If question does not apply, leave blank)

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* Accessibility and Responsiveness:(If question does not apply, leave blank)

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* Quality:(If question does not apply, leave blank)

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* Quality:(If question does not apply, leave blank)

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* a. How did you learn about the Respiratory Virus Immunization Clinic? (Check all that apply)

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* b. In which community did you attend a Respiratory Virus Immunization Clinic?

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* Gender:

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* Ethnicity (Race):

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* Age:

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* Comments:

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* Volunteer Contact Information:

* Dignity, Respect and Trust:
(If question does not apply, leave blank)

* Information Sharing:
(If question does not apply, leave blank)

* Participation:
(If question does not apply, leave blank)

* Accessibility and Responsiveness:
(If question does not apply, leave blank)

* Quality:
(If question does not apply, leave blank)

* Quality:
(If question does not apply, leave blank)

* a. How did you learn about the Respiratory Virus Immunization Clinic?
(Check all that apply)