Example CHQ Survey Form

Demo of CHQ Survey

1. Did receiving this advice from CQH prevent you from referring to a specialist clinic?*
- Yes
- No
2. Did receiving this advice Significantly change the care or next steps in care for your patient?*
No Somewhat Not sure Yes Yes - very much so
3. Did this advice line prevent travel for your patient in anyway?*
- Yes
- No
4. Did receiving this advice support your learning as a HP in the field?*
No Somewhat Not sure Yes Yes - very much so
5. How important do you think it is that this system is available to HP across the state?*
Not sure Not important Somewhat important Very important Critical
General Feedback (Paragraph or Single Line of Text Option)
Example of a Checkbox Option
- First Choice
- Second Choice
- Third Choice
Example of Dropdown