Parish Nurse Questionnaire
in Journal of Christian Nursing, Volume 21, Number 2 Spring 2004
by William (Rick) Parker

DEMOGRAPHICS:

Age (circle response):
  1. 20-30 2. 31-40 3. 41-50 4. 51-60 5. 61-70 6. 71-80 7. 81 or over 
Gender (circle response):
  1. Female 2. Male  
Education Level (circle response):
  1. Diploma 2. Associate Degree 3. BSN 4. MSN 5. PhD 6. Other __________________________
Years Worked in Nursing (circle response):
  1. 0-10 2. 11-20 3. 21-30 4. 31-40 5. 41-over    
Most Recent Area of Nursing other than Parish Nursing (circle 1 response only):
  1. Acute Care 2. Home Care 3. Extended Care 4. Community 5. Other _________________________
Most Recent Area of Practice other than Parish Nursing (circle 1 response only):
  1. Medical/Surgical 2. Critical Care 3. Behavioral 4. Geriatrics 5. Administration 6. Pediatrics
  7. Maternal/Newborn 8. Community 9. Quality Management/ Utilization Review 10. Case Management
  11. Other _______________________________________________________________________________________
Number of Years in Parish Nursing (circle response):
  1. 0-1 2. 2-5 3. 6-9 4. 10 or more  
Current status as a Parish Nurse (circle response):
  1. Paid 2. Volunteer  
Parish Nurse training (circle response):
  1. School of Nursing/University 2. Orientation Program 3. No program
Association/Affiliation (circle response):
  1. Parish Nursing Resource Center (Chicago) 2. Health Ministries Association 3. A.N.A. 4. Other_____________
THE FOLLOWING QUESTIONS REFER TO YOUR CURRENT PARISH NURSE PRACTICE:

CIRCLE YOUR RESPONSE

Do you document the services you provide to parishioners?

  always usually occasionally seldom never
Do you document the outcomes of the services administered to parishioners?
  always usually occasionally seldom never
Do you document your observations of patient conditions?
  always usually occasionally seldom never
Do you document your referrals to health care professionals?
  always usually occasionally seldom never
Do you document the follow-up/ outcomes on referrals made to health care professionals?
  always usually occasionally seldom never
Do you provide a written report to Pastor/Church Staff Person and or Church Board?
  always usually occasionally seldom never
Do you provide a written report to Pastor/Church Staff Person and or Church Board?
  1. Pastor 4. Health Ministry Cabinet
  2. Church Staff Person 5. Hospital Coordinator
  3. Church Board 6. Other_____________________________________________