Items:

Now I will ask you some questions about your experiences with the ASHA (Community Health Worker in India). Thinking back on your last visit with the ASHA, tell me if the following things happened all the time, most of the time, a few times, or it never happened.

You can say a few times if it happened one or two times, and most of the time will be if it happened 3 or more times, but not always. As a reminder, none of the responses that you give will be shared with your ASHA. We ask that you are honest in your responses so that we may understand how ASHAs may provide the best care to their clients.

(PROBE FOR ALL QUESTIONS: if respondent just responds, yes, ask them: Did this occur a few times, most of the time, or all the time)

1. Did the ASHA introduce herself to you when she came to see you?
2. Did the ASHA treat you with respect?
3. Did you feel the ASHA wanted the best for you?
4. Were you given enough information about your care in order for you to feel like you understood what happened?
5. Did you feel like the ASHA involved you in decisions about your care?
6. Did you feel the ASHA clearly explained things to you?
7. When you had questions, did the ASHA answer in a way you could understand?
8. Did the ASHA support your anxieties and fears about your family planning procedure or your choice?
9. Did you feel you could ask the ASHA any questions you had?
10. Did you feel you were allowed to have someone you wanted to stay with you during your visit?
11. Did the ASHA ask you or your family for money other than the official cost?
12. Is the ASHA available to you when you want to speak to her, have questions, or need support?
13. Did you feel the ASHA took the best care of you?
14. Did you feel the ASHA cared about you as a person?
15. Did you feel you had complete trust in the ASHA with regards to your care?

Response Options:
No, never - 0
Yes, a few times - 1
Yes, most of the time - 2
Yes, all the time - 3