Questionnaire template
Community Health Programme Feedback
Collects community members' ratings, ideas and stories about a local health programme to guide improvements.
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Nonprofit · Community. All Nonprofit templates
Questions in this template
Using Our Services
Thank you for sharing your views. They will help us make our community health programme work better for everyone.
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How often do you use the services of our community health programme?
Choose one:
- Daily
- Weekly
- Monthly
- Less than once a month
- Never
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How would you rate our services on each of these?
Condition: Only for people who have used the services
- Overall quality
- How responsive the staff are
- How easy the services are to reach and use
For each row: choose one:
- Poor
- Fair
- Good
- Very good
- Excellent
Your Ideas
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What would you like us to change or add to the programme?
Open answer
Your Experience
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Has the programme made a difference for you or your family? If so, please tell us about it.
Condition: Only for people who have used the services
Open answer
About You
These answers are kept confidential and used only to describe who took part.
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What is your gender?
Choose one:
- Female
- Male
- Non-binary
- Prefer not to say
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How old are you?
A number from 16 to 110