|
A.
|
USER IDENTIFICATION
|
| A2. |
Sex |
1( ) Male |
2( ) Female |
( ) |
| A3. |
Age |
______years |
( ) |
| A4. |
Origin (city/town) |
________________________________________ |
|
| A5. |
Color/Race |
1( ) White |
4( ) Yellow |
( ) |
| 2( ) African American |
5( ) Indigenous |
| 3( ) Brown |
|
| A6. |
Degree of schooling |
1( ) Non-literate |
6( ) Incomplete high school |
( ) |
| 2( ) Incomplete Elementary School I |
7( ) Complete high school |
| 3( ) Complete Elementary School II |
8( ) Incomplete higher education |
| 4( ) Incomplete Elementary School II |
9( ) Complete higher education |
| 5( ) Complete Elementary School II |
10( ) Post-graduation |
| A7. |
Religion |
1( ) Catholic |
4( ) Agnostic |
( ) |
| 2( ) Evangelical |
5( ) Other (specify) |
| 3( ) Spiritist |
|
| A8. |
Marital status |
1( ) Married/Consensual Union |
4( ) Widower |
( ) |
| 2( ) Single |
5( ) Divorced |
| 3( ) Separate |
|
| A9. |
Occupation |
________________________________________ |
|
| A10. |
Income in minimum salaries |
1( ) < 1 salary |
3( ) 3 a 5 salaries |
( ) |
|
|
4( ) 6 a 10 salaries |
|
B.
|
DADOS SOBRE O EVENTO
|
| B1. |
Date of the event ___/___/___ |
Time:_______ |
( ) |
| B2. |
Date of service ___/___/___ |
Time:_______ |
( ) |
| B3. |
Day of the week in which the event occurred |
1( ) Sunday |
5( ) Thursday |
( ) |
| 2( ) Monday |
6( ) Friday |
| 3( ) Tuesday |
7( ) Saturday |
| 4( ) Wednesday |
|
| B4. |
Who transported the victim to the hospital? |
1( ) BHU |
3( ) Rescue Unit (RU) |
( ) |
| 2( ) USA |
4( ) Helicopter |
| B5. |
Place of occurrence (city/neighborhood) |
________________________________________ |
( ) |
| B6. |
Time of occurrence |
________________________________________ |
|
| B7. |
Classification of the event suffered |
1( ) Traumatic |
3( ) Gynecologist-obstetrician |
( ) |
| Which:____________________ |
Which:____________________ |
| 2( ) Clinical |
4( ) Psychiatric |
| Which:__________________ |
Which:____________________ |
| B8. |
Body region (s) reached on occurrence |
1( ) Head/neck |
3( ) Abdomen |
|
| 2( ) Chest |
4( ) MMSS/II and pelvic girdle |
|
|
C.
|
EVALUATION OF SATISFACTION OF THE CARE RECEIVED BY SAMU 192
|
|
Below, are listed aspects about the structure and process for the evaluation of Samu 192. This item must be completed according to the qualification of the service, in accordance with the parameter below:
|
|
1. Terrible
|
2. Bad
|
3. Regular
|
4. Good
|
5. Excellent
|
| C1. |
The state of conservation of ambulances is? |
( ) |
| C2. |
Was the ambulance comfortable, according to your health needs? |
( ) |
| C3. |
Has the access to the Samu, by the number 192, been carried out properly? |
( ) |
| C4. |
Did the ambulance arrive in considerable time to where you were? |
( ) |
| C5. |
Was the reception provided by the professionals of the Samu 192? |
( ) |
| C6. |
Do you think the Samu 192 team has transported you to the most appropriate place, according to the nature of your occurrence? |
( ) |
| C7. |
The safety demonstrated by the staff during your service was? |
( ) |
| C8. |
During the care, has your privacy been preserved? |
( ) |
| C9. |
The humanization during the care provided by the team is? |
( ) |
| C10. |
Have the guidelines on the procedures performed and your health status been provided by the Samu 192 team? |
( ) |
| C11. |
Your relationship with the professionals of Samu was? |
( ) |
| C12. |
In your opinion, have you obtained resolution with the service of the Samu 192? |
( ) |
|
D.
|
YOUR SATISFACTION WITH THE CARE RECEIVED BY SAMU 192 FROM 0 (ZERO) TO 10 (TEN)
|
| GRADE: ___________________ |
