Team-Based Care Assessment Questionnaire Form
Assess how your care team coordinates communication, responsibilities, and follow-through.
Team Overview
Team Name
*
Respondent Role
*
Care Setting/Type
*
Primary Care
Hospital
Long-Term Care
Home Care
Community Health
Behavioral Health
Other
Team Size
*
Assessment Scales
Team communication
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Role clarity
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Care coordination
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Follow-through
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Overall Assessment
Overall rating of team-based care effectiveness
*
1
2
3
4
5
Comments, barriers, or improvement suggestions for team care coordination
Submit Assessment
Should be Empty: