2. Status

   1. 36 Weeks Pregnancy Entrance Survey (after routine visits established)
   2. 18-24mo Postpartum Exit Survey (or anytime exiting program)
4. Instructions:

   Read each statement and choose the response option that is most accurate for you.

6. Since I started working with a public health nurse:
8. I feel my emotional health has improved.
   -- Select One --strongly disagreedisagreeneither agree nor disagreeagreestrongly agreedoes not apply
10. I am more confident that I can reduce or eliminate my use of tobacco.
    -- Select One --strongly disagreedisagreeneither agree nor disagreeagreestrongly agreedoes not apply
12. I am more confident that I can reduce or eliminate my use of alcohol or other drugs.
    -- Select One --strongly disagreedisagreeneither agree nor disagreeagreestrongly agreedoes not apply
14. I am better able to set and achieve goals in my life.
    -- Select One --strongly disagreedisagreeneither agree nor disagreeagree strongly agreedoes not apply
16. I am better able to access community resources.
    -- Select One --strongly disagreedisagree neither agree nor disagreeagreestrongly agreedoes not apply
18. I feel better prepared to parent my new baby.
    -- Select One --strongly disagreedisagreeneither disagree or agreeagreestrongly agreedoes not apply
20. Overall, how satisfied are you with this program?
    -- Select One --1 (not at all)2345 (neutral)678910 (totally)
22. Confidentiality

    As a reminder, all of your answers will remain confidential.

    Thank you for taking this survey and participating in our programs.

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24. 1. Receive an email copy of this form.
25. Email address

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26. Submit

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