‘Questtonmaire for Clinic Kay Holder - Page 3
19.
Sex:
{ ]
{ ]
Male
Female
20.
Years of education.
21.
Years of medical training or health craining.
22.
Highest degree or cartificate ob rained in
medical field.
23.
Place of medical training.
24,
25.
Years of experience in health work.
How well would this person cooperate with clinic workers?
{ }
Geod
{ ]
Poar
{]
.26.
Fair
How well ts this person accepted by the people?
{ ]
{ ]
{ ]
Good
Fair
Poor
CONTINUE ON. 3ACK IF MORE SPACE IS NEEDED
27.
Is a clinic worker of either sex acceptable with che people?
C ]
{ ]
28.
Yes
We
If ne, specity preferred sex:
{ ]
[ ]
Male
Female