Items:

Subscale: Autonomy, Respectful Care and Communication
1. How did you feel about the amount of time you waited? Would you say it was very short, just a little long, somewhat long, or very long?
2. During your time in the health facility did the doctors, nurses, or other health care providers introduce themselves to you when they first came to see you?
3. Did the doctors, nurses, or other health care providers call you by your name?
4. Did the doctors, nurses, or other staff at the facility treat you with respect?
5. Did the doctors, nurses, and other staff at the facility treat you in a friendly manner?
6. Did the doctors, nurses, and other staff at the facility show that they cared about you?
7. Do you feel like your health information was or will be kept confidential at this facility?
8. Did you feel like the doctors, nurses or other staff at the facility involved you in decisions about your FP choice?
9. Did the doctors, nurses or other staff at the facility speak to you in a language you could understand?
10. Did you feel you could ask the doctors, nurses or other staff at the facility any questions you had?
11. Did the doctors and nurses at the facility talk to you about how you were feeling?
12. Did you feel the doctors and nurses paid attention to you during your stay in the facility?
13. Were you allowed to have someone you wanted to stay with you during your visit?
14. Did you feel the doctors, nurses or other staff at the facility took the best care of you?
15. Did you feel you could completely trust the doctors, nurses or other staff at the facility with regards to your care?

Subscale: Health Facility Environment
16. Did you think there was enough health staff in the facility to care for you?
17. Thinking about the wards, washrooms and the general environment of the health facility, will you say the facility was very clean, clean, dirty, or very dirty?
18. Was there water in the facility?
19. Was there electricity in the facility?
20. In general, did you feel safe in the health facility?

Response Options:
Not specified.