Survey Questionnaire Format

A Survey Questionnaire format is the layout in which a survey questionnaire is to be created. The most important aspect in the format is its simplicity, consistency and the target audience. The target audience allows one to know the kind of questions to be included in the survey. They act as a guideline to show how survey questionnaires are to be written. Below is an example of a survey questionnaire format.

Survey Questionnaire on Government Health Services in various Districts

PERSONAL DETAILS

Surname                                 Middle name              Last name

_______________                 ______________        _________________

Age

Below 18 _______

1. _______

25- 45 _______

45 -65 _______

District of residence   _______________

Do you have Health Insurance? ______________
How many government hospitals and clinics are available in your area?

No. of Hospitals _______

No. of Clinics     ________

Are they easily accessible?

______________________________________

If not, what suggestions and recommendations would you make?

_______________________________________________________________

________________________________________________________________

Do the government hospitals and clinics offer the following services for free? Please answers yes / no with reference to these services:

First Aid

Vaccination

Prenatal Care

Postnatal Care

HIV Voluntary Counseling and Testing

Do the government hospitals have the following facilities? Please answer Yes / No

Pharmacy

Laboratory

Qualified nursing staff and doctors
Are the hospitals and clinics equipped to handle emergencies?

________________________________________________________________________

Kindly rate the cost of government health care services in your district

Cheap _________________

Affordable ______________

Expensive________________

Very Expensive____________

……………………………………………………………………………………….. – o:1
A > fo6; tab-stops:list .5in’>6.Is the government efficient in the creation of employment opportunities in the province?

7.Does the education provided in the school system prepare on for the employment opportunities that are available in the province?

Television/Radio

Internet

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