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Hei Tiki Pūmau Evaluation Form
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Hei Tiki Pūmau – Antenatal Service
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Hei Tiki Pūmau Evaluation Form
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
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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
Phone
This field is for validation purposes and should be left unchanged.
