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    Kuesioner Need and Demand

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    Oktina Purwatiningrum
    This document contains a questionnaire about the needs and demands of university students in Surabaya, Indonesia regarding health services, specifically at general outpatient clinics. The questions ask about the respondent's identity, whether they have been sick in the past month, how they took care of themselves when sick, which healthcare services they prefer and prioritize, whether they have visited the general outpatient clinic, what prompted the visit, which healthcare worker treated them, the services received, and facilities available in the waiting room.

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    Kuesioner Need and Demand

    Uploaded by

    Oktina Purwatiningrum
    156 views3 pages
    This document contains a questionnaire about the needs and demands of university students in Surabaya, Indonesia regarding health services, specifically at general outpatient clinics. The questions ask about the respondent's identity, whether they have been sick in the past month, how they took care of themselves when sick, which healthcare services they prefer and prioritize, whether they have visited the general outpatient clinic, what prompted the visit, which healthcare worker treated them, the services received, and facilities available in the waiting room.

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    Kuesioner Need and Demand

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    This document contains a questionnaire about the needs and demands of university students in Surabaya, Indonesia regarding health services, specifically at general outpatient clinics. The questions ask about the respondent's identity, whether they have been sick in the past month, how they took care of themselves when sick, which healthcare services they prefer and prioritize, whether they have visited the general outpatient clinic, what prompted the visit, which healthcare worker treated them, the services received, and facilities available in the waiting room.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    156 views3 pages

    Kuesioner Need and Demand

    Uploaded by

    Oktina Purwatiningrum
    This document contains a questionnaire about the needs and demands of university students in Surabaya, Indonesia regarding health services, specifically at general outpatient clinics. The questions ask about the respondent's identity, whether they have been sick in the past month, how they took care of themselves when sick, which healthcare services they prefer and prioritize, whether they have visited the general outpatient clinic, what prompted the visit, which healthcare worker treated them, the services received, and facilities available in the waiting room.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3

    Nomor : .... / .

    Tanggal wawancara:

    LEMBAR KUESIONER KEBUTUHAN (NEED) DAN PERMINTAAN (DEMAND) MASYARAKAT TERHADAP PELAYANAN KESEHATAN KHUSUSNYA POLI UMUM PADA MAHASISWA ITS SURABAYA 2013 I. Identit ! Re!"#nden 1. Nama 2. Alamat 3. Umur : : : Kurang dari 20 tahun 20-29 Tahun 30-39 Tahun 40 Tahun atau !"ih Be$i t nd %ent n& (' ) (nt() *en+ , -. 4. #!ni$ K!lamin (. &!%!r)aan : : a%i-la%i &!la)ar/*aha$i$wa +uru/,o$!n -ira$wa$ta &N./TN//&olri &!gawai .wa$ta ain-lain0 $!"ut%an... 1. &!ndidi%an T!ra%hir : Tida% Tamat ., Tamat ., Tamat .*&/. T& Tamat .*A/. TA Tamat &!rguruan Tinggi 2.1 atau !"ih3 &!r!m'uan

    Pi/i0 ! / 0 ! t( + , - n den& n % $ *en1i/ n& (2) t ( i)(ti "et(n+() 1 n& te$te$ " d "e$t n1 n. II. Ke-(t(0 n (Need) Pe/ 1 n n Ke!e0 t n 1. A'a%ah Anda '!rnah $a%it dalam %urun wa%tu 1 "ulan t!ra%hir4 a. 5a ". Tida% 2. A'a 6ang a%an Anda la%u%an %!ti%a $!dang $a%it4 a. &!rgi %! '!la6anan %!$!hatan ". *!ngo"ati $!ndiri c. ,i"iar%an $a)a d. *!manggil tu%ang 'i)at !. ain-lain0 $!"ut%an .. 3. #i%a Anda m!m!ri%$a%an diri $aat $a%it0 %! mana Anda a%an m!m!ri%$a%an diri4 a. &!la6anan %!$!hatan ". &!ngo"atan alt!rnati7 c. ,u%un atau ta"i" d. Tu%ang 'i)it !. ain-lain0 $!"ut%an.. 4. #i%a Anda m!m!ri%$a%an diri %! '!la6anan %!$!hatan0 '!la6anan %!$!hatan a'a 6ang Anda "utuh%an4 a. &u$%!$ma$ ". 8umah $a%it c. Klini% d. ,o%t!r 'ra%ti% atau "idan 'ra%ti% !. ain-lain0 $!"ut%an.. (. &ada $aat Anda "!ro"at0 )!ni$ '!la6anan a'a 6ang Anda "utuh%an4 2"ol!h l!"ih dari 1 )awa"an3 a. &oli umum ". &oli gigi c. a"oratorium d. &oli K/A !. ain-lain0 $!"ut%an

    1. .ia'a%ah t!naga %!$!hatan 6ang Anda "utuh%an untu% m!nangani Anda 'ada $aat "!ro"at4 a. ,o%t!r ". 9idan c. &!rawat d. ,u%un t!rlatih !. ain-lain0 $!"ut%an.. 1. A'a 6ang " /in& m!n)adi '!rtim"angan Anda dalam m!milih '!la6anan %!$!hatan4 a. ,!%at d!ngan lo%a$i t!m'at tinggal ". :a$ilita$ l!ng%a' c. T!m'at n6aman d. &!tuga$ ramah !. 9ia6a t!r)ang%au ;. :a$ilita$ a'a 6ang Anda "utuh%an di $( n& t(n&&( '!la6anan %!$!hatan4 2Urut%an $!$uai 'riorita$0 1 untu% 'riorita$ utama0 d$t.3 a. T!m'at dudu% 6ang n6aman ". Ki'a$ angin / A< c. *a)alah / "ahan "acaan d. Alat '!nd!ngar mu$i% !. ain-lain0 $!"ut%an =. :a$ilita$ (*(* a'a 6ang Anda "utuh%an di '!la6anan %!$!hatan4 2Urut%an $!$uai 'riorita$0 1 untu% 'riorita$ utama0 d$t.3 a. T!m'at i"adah ". <a7!taria c. Taman d. T!m'at 'ar%ir !. ain-lain0 $!"ut%an

    III. Pe$*int

    n (Demand) Pe/ 1 n n Ke!e0 t n

    1. ,alam %urun wa%tu 1 "ulan t!ra%hir0 a'a%ah Anda '!rnah $a%it4 a. 5a ". Tida% 2. A'a%ah 6ang Anda la%u%an $aat $a%it 4 a. &!rgi %! '!la6anan %!$!hatan ". *!ngo"ati $!ndiri c. ,i"iar%an $a)a d. *!manggil tu%ang 'i)it !. ain-lain0 $!"ut%an.. 3. #i%a Anda m!m!ri%$a%an diri $aat $a%it0 %! mana Anda m!m!ri%$a%an diri4 a. &!la6anan %!$!hatan ". &!ngo"atan alt!rnati7 c. ,u%un atau ta"i" d. Tu%ang 'i)at !. ain-lain0 $!"ut%an.. 4. #i%a Anda m!m!ri%$a%an diri %! '!la6anan %!$!hatan0 '!la6anan %!$!hatan mana 6ang " /in& !e$in& Anda %un)ungi4 a. &u$%!$ma$ ". 8umah $a%it c. Klini% d. ,o%t!r atau "idan 'ra%ti% !. ain-lain0 $!"ut%an.. (. A'a%ah Anda '!rnah "!ro"at %! &oli Umum dalam %urun wa%tu 1 "ulan t!ra%hir4 a. 5a ". Tida%

    1. .ia'a%ah 6ang m!ndorong Anda untu% m!ngguna%an '!la6anan &oli Umum4 a. ,iri $!ndiri ". T!man c. T!tangga d. K!luarga !. ain-lain0 $!"ut%an ;. A'a 6ang " /in& m!ndorong Anda untu% m!ngguna%an '!la6anan &oli Umum4 29ol!h l!"ih dari 1 )awa"an3 a. ,!%at d!ngan %am'u$ ". :a$ilita$ l!ng%a' c. T!m'at n6aman d. &!tuga$ ramah !. 9ia6a t!r)ang%au =. .ia'a%ah t!naga %!$!hatan 6ang m!nangani Anda 'ada $aat "!ro"at4 a. ,o%t!r ". 9idan c. &!rawat d. ,o%t!r $'!$iali$ !. ain-lain0 $!"ut%an.. 9. &!la6anan %!$!hatan a'a 6ang Anda da'at%an $aat "!ro"at %! &oli Umum4 29ol!h l!"ih dari 1 )awa"an3 a. &!m!ri%$aan t!%anan darah ". &!m!ri%$aan d!n6ut nadi c. &!m"!rian o"at-o"atan d. &!m"!rian Health Education 7. ain-lain0 $!"ut%an.. 10. :a$ilita$ a'a 6ang Anda da'at%an di ruang tunggu &oli Umum4 29ol!h l!"ih dari 1 )awa"an3 a. T!m'at dudu% 6ang n6aman ". Ki'a$ angin / A< c. *a)alah / "ahan "acaan d. Alat '!nd!ngar mu$i% !. ain-lain0 $!"ut%an.

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