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. 2016 Oct 18;16:583. doi: 10.1186/s12913-016-1810-y

Table 2.

Feedback survey on systems assessment tool (SAT)

ᅟ
1. Date of completion:     /  /  /
2. Your name (optional): ______________________________________________
3. What is your role/position: __________________________________________
4. Name of your health service (or area or region that you look after) : _______________________________________
   a. Location of health service ( please circle ): Urban/Regional/Remote
5. Has your health service (or any of the services that you facilitate) used the SAT in the last 12 months? Yes [ ]– go to Q8. No [ ]– go to Q6 (please place X in the appropriate box here and for questions below)
6. Has your health service (or services that you look after) previously used the SAT? Yes [ ] – go to Q7. No [ ] – go to Q10 (Could you please comment in Q10 on why the SAT has not been used?)
7. How long ago was the last use of SAT in your service (or service that you facilitate?)
   Service 1 [--.—years ago]
   Service 2 [--.—years ago]
   Service 3 [--.—years ago]
8. Thinking of the most recent use of the SAT tool you were involved in:
    a. Approximately how many service people participated in the SAT session? ___
    b. Who participated in the assessment?
      (1) nurse                       [Yes__][No__]
      (2) Aboriginal and/or Torres Strait Islander Health Worker    [Yes__] [No__]
      (3) administrative staff                  [Yes__] [No__]
      (4) management staff                  [Yes__] [No__]
      (5) general practitioner                 [Yes__] [No__]
      (6) allied health staff                  [Yes__] [No__]
      (7) driver                       [Yes__] [No__]
      (8) community representatives              [Yes__] [No__]
      (9) service clients                    [Yes__] [No__]
      (10) staff from other organisations             [Yes__] [No__]
      (11) other.[Yes__][No__] If yes, what was their role/ position?: ___________________________________________
   c. Did the health service benefit from using the SAT? Yes []: please explain what the benefits were: If No []: - go to 8d:
      (1)_______________________________________________________________________________________________________
      (2)____________________________________________________________________________________
    d. Were any problems or difficulties experienced with the last use of SAT?
      (1)____________________________________________________________________________________
      (2)____________________________________________________________________________________
    e. Did the health service make any practice changes as a result of findings from the SAT?
      (1) Yes [ ] Go to Q8f
      (2) No [ ] – Do you know why not? ____________________________________________________________________________
    f. What changes did the health service make? _______________________________________________________________________
9. Please provide feedback on the different ways the SAT tool is being delivered or facilitated:
_____________________________________________________________________________________________________________________
_________________________________________________________________________________________________
10. Do you have any other comments?
_____________________________________________________________________________________________________________________