APPENDIX D

SAMPLE QUESTIONNAIRE FOR PATIENTS

Sample Questionnaire for Patients - PDF file

 

We understand that you had a clown visitor today! Hopefully it was a pleasant and enjoyable experience. We would like your help in making our Caring Clown Program a success. Please take a minute and fill out this survey. Your opinion is very important to the members of the Humor Committee. We will use this information to make our Caring Clown Program better for future patients.

 

Please answer the following questions using a scale of 1 to 7, with 1 being ‘I never want to see another clown again’ and 7 being ‘The clown visit was the highlight of my day.’ Circle the number that best reflects your visit with the clown.

 

v    I enjoyed having a clown visit me.

 

1          2            3            4            5            6            7

 

v    The clown was polite, courteous and friendly.

 

1          2            3            4            5            6            7

 

v    I would recommend this clown to a friend.

 

1          2            3            4            5            6            7

 

v    I would enjoy having this clown visit again.

 

1          2            3            4            5            6            7

 

Please complete the following remarks.

 

My favorite part of the visit was…

 

 

Some suggestions I have to make for the clown program are…

 

 

 

How did the clown visit make you feel?

 

 

Please provide any additional comments you wish to make about the visit:

 

 

 

You can leave this survey at the nurse’s station. Our ‘clown leader’ will pick it up.

 

Thank You!  Thank You! Your help is greatly appreciated!  Thank You!  Thank You!