13 Clinet Opinion Form

Client Opinion Form

The Patient Navigator Program is funded by the Health Resources and Services Administration (HRSA) to help people with their health care. We want to learn whether the Patient Navigator Program was helpful to you so we can make the program better.

• Answers from everyone who completes the survey will be given to HRSA.

• Your name will not be reported. No one will know what answers are from you.

• You may skip any question you wish. If you choose to not respond, it will not affect your health care.

• Your input will help us improve the program. Your views are important--thanks for your help!

Please answer each question below by marking an ‘X’ next to the best answer. For example,

What is your gender?

Male

Female

Patient Navigators help people with different things. We want to know what kind of help you received from the Patient Navigator and what you thought about it.

If you did not need help with an activity just mark the box or say, “I did not need help with that.”

1. Did the Patient Navigator help you make appointments for visits to the doctor, medical tests, or other health care?

Not at all

A little

Somewhat

A lot

I did not need help with that

2. Did the Patient Navigator help you arrange transportation to your appointments?

Not at all

A little

Somewhat

A lot

I did not need help with that

3. Did the Patient Navigator help you get medical equipment or prescriptions?

Not at all

A little

Somewhat

A lot

I did not need help with that

4. Did the Patient Navigator help you find ways to pay for health care?

Not at all

A little

Somewhat

A lot

I did not need help with that

5. Did the Patient Navigator help you learn about services available in your community, such as housing, utilities, food, or childcare?

Not at all

A little

Somewhat

A lot

I did not need help with that

6. Did the Patient Navigator help you to speak with or understand your doctors?

Not at all

A little

Somewhat

A lot

I did not need help with that

7. Did the Patient Navigator help you learn about the need for cancer screening tests and routine checkups?

Not at all

A little

Somewhat

A lot

I did not need help with that

8. Did the Patient Navigator help and encourage you to reach for the health goals set by your doctor?

Not at all

A little

Somewhat

A lot

I did not need help with that

9. Some clinics have connections with Clinical Trials. If you were referred to a Clinical Trial, did the Patient Navigator help you get information about it?

Not at all

A little

Somewhat

A lot

I did not need help with that

We’d also like to learn what it was like working with a Patient Navigator.?

10. Did the Patient Navigator give you the information or help you needed?

Never

Sometimes

Usually

Always

11. Did the Patient Navigator explain things in a way that was easy to understand?

Never

Sometimes

Usually

Always

12. Did the Patient Navigator listen carefully to you?

Never

Sometimes

Usually

Always

13. Using any number from 0 to 10, where 0 is the worst experience possible and10 is the best experience possible, what number would you use to rate your experience with the Patient Navigator Program?

0 Worst experience possible

1

2

3

4

5

6

7

8

9

10 Best experience possible

14. Before you enrolled in the Patient Navigator Program, when was the last time you had seen a doctor or nurse?

Within the last year

1 to 3 years ago

3 to 5 years ago

5 years ago or more

I had never seen a doctor or nurse

OPTIONAL: If you would like to tell us more…

15. How has the Patient Navigator Program been most useful to you?

16. What parts of the Patient Navigator Program have been least helpful?

17. What would you change about the Patient Navigator Program if you could?

The Patient Navigator Program is funded by the Health Resources and Services Administration (HRSA) to help people with their health care. We want to learn whether the Patient Navigator Program was helpful to you so we can make the program better.

• Answers from everyone who completes the survey will be given to HRSA.

• Your name will not be reported. No one will know what answers are from you.

• You may skip any question you wish. If you choose to not respond, it will not affect your health care.

• Your input will help us improve the program. Your views are important--thanks for your help!

Please answer each question below by marking an ‘X’ next to the best answer. For example,

What is your gender?

Male

Female

Patient Navigators help people with different things. We want to know what kind of help you received from the Patient Navigator and what you thought about it.

If you did not need help with an activity just mark the box or say, “I did not need help with that.”

1. Did the Patient Navigator help you make appointments for visits to the doctor, medical tests, or other health care related to cancer?

Not at all

A little

Somewhat

A lot

I did not need help with that

2. Did the Patient Navigator help you arrange transportation to your cancer-related appointments?

Not at all

A little

Somewhat

A lot

I did not need help with that

3. Did the Patient Navigator help you get cancer-related medical equipment or prescriptions?

Not at all

A little

Somewhat

A lot

I did not need help with that

4. Did the Patient Navigator help you find ways to pay for cancer-related health care?

Not at all

A little

Somewhat

A lot

I did not need help with that

5. Did the Patient Navigator help you learn about services available in your community, such as housing, utilities, food, or childcare?

Not at all

A little

Somewhat

A lot

I did not need help with that

6. Did the Patient Navigator help you to speak with or understand your doctors?

Not at all

A little

Somewhat

A lot

I did not need help with that

7. Did the Patient Navigator help you learn about the need for cancer screening tests and routine checkups?

Not at all

A little

Somewhat

A lot

I did not need help with that

8. Did the Patient Navigator help and encourage you to reach for the health goals set by your doctor?

Not at all

A little

Somewhat

A lot

I did not need help with that

9. Some clinics have connections with Clinical Trials. If you were referred to a Clinical Trial, did the Patient Navigator help you get information about it?

Not at all

A little

Somewhat

A lot

I did not need help with that

10. We’d also like to learn what it was like working with a Patient Navigator. Did the Patient Navigator give you the information or help you needed?

Never

Sometimes

Usually

Always

11. Did the Patient Navigator explain things in a way that was easy to understand?

Never

Sometimes

Usually

Always

12. Did the Patient Navigator listen carefully to you?

Never

Sometimes

Usually

Always

13. Using any number from 0 to 10, where 0 is the worst experience possible and 10 is the best experience possible, what number would you use to rate your experience with the Patient Navigator Program?

0 Worst experience possible

1

2

3

4

5

6

7

8

9

10 Best experience possible

OPTIONAL: If you would like to tell us more…

14. How has the Patient Navigator Program been most useful to you?

15. What parts of the Patient Navigator Program have been least helpful?

16. What would you change about the Patient Navigator Program if you could?

1/30/2021