Hei Tiki Pūmau Evaluation Form

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Hei Tiki Pūmau Evaluation Form

Home » Hei Tiki Pūmau – Antenatal Service » Hei Tiki Pūmau Evaluation Form

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Hei Tiki Pūmau Evaluation Form
I am completing this for*
Please select an option below
- Hei Tiki Pūmau Māmā Evaluation Form
- Hei Tiki Pūmau Whānau Evaluation Form
Date*
Date Format: DD slash MM slash YYYY
Name
Your name
Email*
Hāpu
Your name
Whānau Mai
Your name
- 1-Very Well
- 2-Above Average
- 3-Average
- 4-Below-Average
- 5-Poor
1. Huria Trust Hauora Service(s)
Please Tick
1.1 Did the service(s) meet your needs*
1. Very Well – 5. Poor
- 1
- 2
- 3
- 4
- 5
1.2 Did the service(s) assist in improving your health and wellbeing?*
1. Very Well – 5. Poor
- 1
- 2
- 3
- 4
- 5
1.3 Did we assist you in a friendly, courteous and timely manner when you accessed the service(s)?*
1. Very Well – 5. Poor
- 1
- 2
- 3
- 4
- 5
What did you like about the service?
Please comment
Where can we improve?
Recommendations
2. Huria Trust Kaiāwhina
Please tick
2.1 Did the Kaiāwhina engage with you in a timely manner?*
1. Very Well – 5. Poor
- 1
- 2
- 3
- 4
- 5
2.2 Did the Kaiāwhina regularly inform or update you throughout the services(s) provided to you?*
1. Very Well – 5. Poor
- 1
- 2
- 3
- 4
- 5
2.3 Did the Kaiāwhina provide you with enough information to make informed decisions about your health & wellbeing?*
1. Very Well – 5. Poor
- 1
- 2
- 3
- 4
- 5
Comments
3. Overall
3.1 Did we provide a quality service to you and/or your whānau?*
1. Very Well – 5. Poor
- 1
- 2
- 3
- 4
- 5
3.2 Were our services delivered in a culturally responsive manner?*
1. Very Well – 5. Poor
- 1
- 2
- 3
- 4
- 5
3.3 Did our facilities enable you to access the service(s) with ease?*
1. Very Well – 5. Poor
- 1
- 2
- 3
- 4
- 5
Comments
3.4 Would you recommend this service to your whānau?
1. Very Well – 5. Poor
- Yes
- No
3.5 Would you utilise this service again?
1. Very Well – 5. Poor
- Yes
- No
4. Additional Information
Hei Tiki Pūmau Māmā Evaluation Form
BREASTFEEDING: HAPŪ
Based on your prior knowledge, and the information you have received during the Hei Tiki Pumau programme, are you intending to Breastfeed your pēpī?*
- Yes
- Not sure
- No
If no, or you are not sure, would you like more information about Breastfeeding?*
- Yes
- No
BREASTFEEDING: WHĀNAU MAI
Are you Breastfeeding pēpī?*
- Yes
- No
- Not Applicable
How long have you been Breastfeeding pēpī for?
IMMUNISATION: HAPŪ
Based on your prior knowledge, and the information you have received during the Hei Tiki Pumau programme, are you intending to Immunise your pēpī*
- Yes
- Not sure
- No
If no, or you are not sure, would you like more information about Immunisation?*
- Yes
- No
*IMMUNISATION: WHĀNAU MAI
Have you immunised pēpī?*
- Yes
- No
If no, was this an informed decision?*
- Yes
- No
Is pēpī up to date with immunisations?*
- Yes
- No
HEALTH
Based on your prior knowledge, and the information you have received during the Hei Tiki Pumau programme, are you intending to or have stopped smoking?*
- Yes
- Not sure
- No
Based on your prior knowledge, and the information you have received during the Hei Tiki Pumau programme, are you intending to or have stop consuming alcohol or non-prescription drugs?*
- Yes
- Not sure
- No
HMT POST PROGRAMME SUPPORT & ASSISTANCE
Would you like Huria Trust to provide on-going assistance and/or support?*
- On-going support during your pregnancy and birth
- On-going support post birth
SUPPORT SERVICE ASSISTANCE
Would you like Huria Trust to assist and support you to access the following services?*
- Support to Access LMC (Lead Maternity Carer) and/or Midwife
- Education Service(s) (Diabetes)
- Education Service(s) (Cardiovascular Disease)
- Risk Assessment (Cardiovascular Disease)
- Education Service(s) (Vaccination)
- Access to a GP service (for those not currently registered with a GP)
- Follow Up referral to GP service
- Support to Access Smoking Cessation Service(s)
- Support to Access Social Service Agencie(s)
- Support to Access Mammography Service(s)
- Support to Access any Parenting Programme(s)
- Support to Access Health Service(s) for you or your whānau
- Support to Access the Green Prescription Programme
- Support to Access Breast Feeding Agencies
- Support to Access Asthma Management Agencies
- Support to Access Preschool Dental Care for other Whānau Members
PREGNANCY SUPPORT
Have you engaged with any Maternity services during and/or post pregnancy?*
- Yes
- No
Which service provider(s) assisted you during and post pregnancy?
On a scale of 1 to five 1 being very good – 5 being poor, please rate your Maternity service experience*
- 1
- 2
- 3
- 4
- 5
Please explain the reason for the rate you gave:*
4. Additional Information
Hei Tiki Pūmau Whānau Evaluation Form
POST PROGRAMME SUPPORT & ASSISTANCE
Would you like Huria Management Trust to provide on-going assistance and/or support?*
- On-going support during the pregnancy and birth for you and/or the pregnant Māmā you are here to support
- On-going support post birth for you and/or the pregnant Māmā you are here to support
- No further support is required
EXTERNAL SUPPORT SERVICE ASSISTANCE
Would you like Huria Trust to assist and support you to access the following services?*
- Support to Access LMC (Lead Maternity Carer) and/or Midwife
- Education Service(s) (Diabetes)
- Education Service(s) (Cardiovascular Disease)
- Risk Assessment (Cardiovascular Disease)
- Education Service(s) (Vaccination)
- Access to a GP service (for those not currently registered with a GP)
- Follow Up referral to GP service
- Support to Access Smoking Cessation Service(s)
- Support to Access Social Service Agencie(s)
- Support to Access Mammography Service(s)
- No further support is required
EXTERNAL SUPPORT SERVICE ASSISTANCE CONTINUED
Would you like Huria Trust to assist and support you and/or the pregnant Māmā you are here to support access the following services?*
- Support to Access the Green Prescription Programme
- Support to Access Breast Feeding Agencies
- Support to Access Asthma Management Agencies
- Support to Access Preschool Dental Care for other Whānau Members
- No further support is required
Email
This field is for validation purposes and should be left unchanged.

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Hei Tiki Pūmau Evaluation Form

Services

Hei Tiki Pūmau Evaluation Form

1. Huria Trust Hauora Service(s)

2. Huria Trust Kaiāwhina

3. Overall

4. Additional Information

4. Additional Information

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