Name

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First Name

Last Name

How would you rate your overall experience during early labor at our birth center?

Very Poor

Poor

Neutral

Good

Excellent

Did you feel supported during triage and early labor?

No

Somewhat

Yes

How well did the staff do in involving you in shared decision-making during early labor?

Very Poor

Poor

Neutral

Good

Excellent

How would you rate your overall experience during active labor and birth at our birth center?

Very Poor

Poor

Neutral

Good

Excellent

Did you have a doula for your birth?

Yes

No

Did you feel supported by the staff during active labor and birth?

Never

Sometimes

Neutral

Most of the time

Always

How would you rate the level of communication from the staff during active labor and birth?

Very Poor

Poor

Neutral

Good

Excellent

Did you feel you were involved in decision-making during labor and birth?

Never

Sometimes

Neutral

Most of the time

Always

Did you feel informed consent was always provided during labor and birth?

No

Somewhat

Yes

How would you rate your overall experience with immediate postpartum care at the birth center?

Very Poor

Poor

Neutral

Good

Excellent

How well did the staff support you in the immediate postpartum period?

Very Poor

Poor

Neutral

Good

Excellent

How safe did you feel during your time at the birth center?

Not safe at all

Not safe

Neutral

Safe

Very Safe

Did you have any safety concerns during your stay at the birth center?

Major concerns

Some concerns

No concerns

How would you rate the professionalism of the staff at our birth center?

Very Poor

Poor

Neutral

Good

Excellent

How would you rate the cleanliness and comfort of the birth center during your stay?

Very Poor

Poor

Neutral

Good

Excellent

Would you recommend the Birth Center to others?

Yes

No

Maybe