Regional Perinatal System


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	Evaluation

Pregnancy Passport
>> Survey

	You are any of the following:

	CNM MD RN CNS CNA MA Other healthcare provider

	Thank you for participating in this important survey. Please take 5-10 minutes to answer the following questions based on your experience with the Pregnancy Passport so far. Your feedback is very important. Thank you!

	Clinic name (optional)


	Your name (optional)


1)	Do you feel that the Pregnancy Passport is a valuable tool for improving quality of care at your clinic? (1= not at all, 5= extremely)


	Please tell us why or why not:


2)	Do you feel that the Pregnancy Passport is a valuable tool for improving continuity of care with your patients? (1= not at all, 5= extremely)


	Please tell us why or why not:


3)	Does the Pregnancy Passport enhance discussion of preterm labor with patients? (1= not at all, 5= extremely)


	Please tell us why or why not:


4)	Do you support the concept of a handheld prenatal medical record for women to carry? (1= not at all, 5= extremely)


	Please tell us why or why not:


5)	Do you support the concept of using the Pregnancy Passport to reinforce education about preterm labor, including how to act on symptoms? (1= not at all, 5= extremely)


	Please tell us why or why not:


6)	Do you feel that the Pregnancy Passport enhances communication between women and their providers? (1= not at all, 5= extremely)


	Please tell us why or why not:


7)	What percentage of your patients receives a Pregnancy Passport?
	%

8)	Among those women who receive a Pregnancy Passport, what percentage brings them to at least one subsequent visit? % (approximate)
	%

9)	To your knowledge, did any of your patients who received a Pregnancy Passport seek care for signs/symptoms of preterm labor or other pregnancy complications?
	Yes No

	Please tell us why or why not:


10)	What changes would you suggest making to the content of the Pregnancy Passport?


11)	What changes would you suggest making to the design of the Pregnancy Passport?


12)	Please share any other comments or suggestions: