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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