Client Exit Interview Template

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Appendix IV.1
Form 4—Clinic
Client Exit Interviews
GENERAL INFORMATION (FILL IN THIS SECTION BEFORE THE INTERVIEW)
1. Interviewer ___________________________________________________________________
2. Evaluation coordinator _______________________
3. Position in the institution _____________
4. Institution__________________________________________________________________
Primary
5. Clinic _________________
6. Level of care
Secondary
Tertiary
Specialty
7. Municipality ________________________
8. Department_________________________
9. Date_____/_____/_____ (day/month/year)
CLIENT INFORMED CONSENT (READ WORD FOR WORD):
We are studying the quality of care that health personnel in this clinic provide to clients. I will ask you questions
regarding the interaction and treatment of the persons who attended you during your visit as well as the services you
received. I do not need to know your name, and your answers will be completely confidential. If you decide not to
participate, the treatment or services you will need in the future will be provided without a change. Do you agree to
have this interview?
(IF THE CLIENT DOES NOT ACCEPT, THANK HIM OR HER AND END THE INTERVIEW.)
IF THE CLIENT ACCEPTS, ASK:
10. What was the main reason for your visit?
a. Counseling on contraception
b. STI counseling
c. Ob-gyn consultation
1. Contraceptive consultation
2. Breast examination
3. Pap smear
4. STI diagnosis or treatment
5. Gynecology (general)
6. Pregnancy (prenatal visit)
7. Postpartum
1
Quality
and
Gender
Accreditation
Reference
Guides
Appendix
IV.1
Clinic
Client
Exit
Interviews
Appendix IV.1
Form 4—Clinic
Client Exit Interviews
GENERAL INFORMATION (FILL IN THIS SECTION BEFORE THE INTERVIEW)
1. Interviewer ___________________________________________________________________
2. Evaluation coordinator _______________________
3. Position in the institution _____________
4. Institution__________________________________________________________________
Primary
5. Clinic _________________
6. Level of care
Secondary
Tertiary
Specialty
7. Municipality ________________________
8. Department_________________________
9. Date_____/_____/_____ (day/month/year)
CLIENT INFORMED CONSENT (READ WORD FOR WORD):
We are studying the quality of care that health personnel in this clinic provide to clients. I will ask you questions
regarding the interaction and treatment of the persons who attended you during your visit as well as the services you
received. I do not need to know your name, and your answers will be completely confidential. If you decide not to
participate, the treatment or services you will need in the future will be provided without a change. Do you agree to
have this interview?
(IF THE CLIENT DOES NOT ACCEPT, THANK HIM OR HER AND END THE INTERVIEW.)
IF THE CLIENT ACCEPTS, ASK:
10. What was the main reason for your visit?
a. Counseling on contraception
b. STI counseling
c. Ob-gyn consultation
1. Contraceptive consultation
2. Breast examination
3. Pap smear
4. STI diagnosis or treatment
5. Gynecology (general)
6. Pregnancy (prenatal visit)
7. Postpartum
1
Quality
and
Gender
Accreditation
Reference
Guides
Appendix
IV.1
Clinic
Client
Exit
Interviews
d. Other (specify, write clearly)_________________________________________
IF THE MAIN REASON FOR HIS OR HER VISIT IS NOT RELATED TO A SEXUAL AND REPRODUCTIVE
HEALTH SERVICE, THANK THE CLIENT FOR HIS OR HER TIME AND END THE INTERVIEW.
SEX OF THE CLIENT
N
Question
Answer
Pass Std
o
Check the box for the client’s sex
Male
11
Female
CLIENT COMFORT AND WAITING TIME
N
Question
Answer
Pass Std
o
12 Is it difficult for you to come to this clinic during consultation hours?
Yes
No
V.11
Did you have any difficulty coming to the clinic today? For example, did you
Yes
No
IV.1
have to find someone to take care of your children or request permission at
13
work? (ONLY MARK YES IF THE DIFFICULTY IS DIRECTLY RELATED TO
GENDER ISSUES.)
Did you wait more than half an hour to be attended?
Yes
No
II.17
14
Did any educational activity take place in the waiting room while you waited?
Yes
No
VII.4
15
CLIENT-PROVIDER INTERACTION AND TREATMENT
N
Question
Answer
Pass Std
o
In general, during your visit today did you feel that any person in this clinic did
Yes
No
V.9
16
not treat you well?
Would you rather be seen by a man or a woman?
Man
17
Woman
Either
Who saw you during your visit/counseling session: a man or a woman?
Man
18
20
Woman
FILL OUT LATER: Was the client seen by a provider of the sex they prefer?
Yes
N
V.10
19
(BASED ON QUESTIONS 17 AND 18)
o
Did you feel comfortable speaking with the provider today?
Yes
N
V.6
20
o
2
Quality
and
Gender
Accreditation
Reference
Guides
Appendix
IV.1
Clinic
Client
Exit
Interviews
CLINIC CONDITIONS
N
Question
Answer
Pass Std
o
Did different areas in the health clinic seem uncomfortable to you, such as
Yes
No
21
hallways, consulting rooms, bathrooms?
Did any areas in the health clinic seem dirty to you?
Yes
No
22
24
FILL OUT LATER: Did the client find the areas in the health clinic
Yes
No
V.2
23
uncomfortable or dirty? (BASED ON QUESTIONS 21 AND 22)
CONTENTS OF THE CONSULTATION OR COUNSELING SESSION
N
Question
Answer
Pass Std
o
In your visit today, did the provider talk to you about:
How to prevent STIs?
Yes
No
24
How to prevent HIV infection?
Yes
No
25
How to prevent cervical or uterine cancer?
Yes
No
26
How to prevent breast cancer?
Yes
No
27
How to prevent an unwanted pregnancy?
Yes
No
28
30
FILL OUT LATER: Did the provider talk to the client about at least two of
Yes
No
II.4
29
these sexual and reproductive health topics? (BASED ON QUESTIONS 24 –
28)
Did the provider ask whether you are satisfied or dissatisfied with your sexual
Yes
No
30
life?
Did the provider ask whether you have been abused or suffer violence in
Yes
No
31
sexual relations?
Did the provider ask whether your partner participates in preventing unwanted
Yes
No
32
pregnancies?
Did the provider ask whether you can negotiate the use of condoms with your
Yes
No
33
partner?
35
FILL OUT LATER: Did the provider talk to the client about at least two of
Yes
No
II.5
34
these issues? (BASED ON QUESTIONS 30 TO 33)
3
Quality
and
Gender
Accreditation
Reference
Guides
Appendix
IV.1
Clinic
Client
Exit
Interviews
N
Question
Answer
Pass Std
o
Did the provider who attended you today use words that were easy to
Yes
No
II.8
35
understand?
Did the provider who attended you today use educational materials such as
Yes
No
II.7
36
brochures or posters to help you understand the information provided?
Do you think the time the provider spent in consultation with you was
Yes
No
V.8
37
sufficient?
38 Did you feel comfortable asking the provider questions?
Yes
No
V.7
Did the provider clarify your concerns and answer your questions?
Yes
No
II.13
39
END
THANK THE CLIENT
4
Quality
and
Gender
Accreditation
Reference
Guides
Appendix
IV.1
Clinic
Client
Exit
Interviews

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