CATHCA General Questionnaire–2015

How do we use the information we ask for?

-to provide reports to international and local funders and government on Catholic healthcare

-to keep CATHCA fully informed, so we provide what you need and want

-for funding applications( that could include your organisation)

If we know about you, it is easier for us to support you. It is VERY important that you complete all the questions. Thank you for taking the time to assist us!

1. GENERAL INFORMATION (please complete ALL sections)

Name of organisation
NPO number: / PBO Registration number:
Membership Fee Paid: Yes/No? / Date :
No of years in operation: / Province: / Diocese:
City: / Country:
District: / Sub District:
Physical address
Postal address / Postal code:
E-mail / Fax
Cell no / Alternative cell no
Landline tel no / Website
Contact person: / Job title:

2. MEMBER /ORGANISATION TYPE OF WORK

a. Please tick all those that you do

Hospital / Care of the Aged
Clinic / Orphans and Vulnerable Children
Hospice / Mental Health Facility
Home Based Care / Peer Education
Mobile Clinic / Other: (specify)
  1. Please tick the services you provide and add any not listed.

Type of work done
  1. Hospital (Please specify the services you offer)
Number of beds.
  1. Clinic (average number of patients seen per month =………….)
  1. Primary Care and Health Promotion
  2. Child Health: includes nutrition and development
  3. Support to people infected and affected by HIV/AIDS
  4. Distribute ARV treatment to patients
  5. Ante Natal and Post Natal Care, including PMTCT
  6. TB screening and care
  7. Other:

  1. Hospice (Please specify the services you offer)
Number of beds.
  1. Home Based Care (No. of people cared for on regular basis = 593)
  1. Home Visits
  2. Nutrition Packs
  3. FoodGardens
  4. Income Generation
  5. Accessing Social Grants
  6. Palliative care/support
  7. T.B Identification and Care
  8. Other (give details)

  1. Orphans and Vulnerable Children (no. of OVCs currently cared for = 654……………)
  1. Psychosocial support groups
  2. Orphanage/Children’s Home
Number of beds
  1. Community care/visits
  2. Day Care Centre/Crèche
  3. After-school care and food
f. Other:
  1. Mobile Clinics (Please specify the services you offer)

  1. Mental Health Facilities (No. of people currently cared for = ………………)

  1. Care for the Elderly (No. of elderly currently cared for = ………………..)
  2. Old Age Home
Number of beds.
  1. Old Age Day Centre
  2. Home/Community visits
  3. Other

9. Other Services you provide
  1. Soup Kitchen
  2. Health Education
  3. Training (please say what type of training)Victim Empowerment and Support. CHC Level 2,3, and 4 and Child and Youth Care Work
  4. Health Campaigns
  5. Other (please specify)

Other (please list)

3. YOUR STAFF

a. Please list below what staff you have.

Number in total / How many have been trained? / Position funded by
Government / Other Funder / Not funded
Director
Project coordinator/manager
Finance manager/bookkeeper
Supervisor
Caregivers
Administrative/office staff
Professional Nurse
Enrolled Nurse
Doctor
Social worker
Domestic worker
Monitoring & evaluation officer
Driver
Fundraiser
Gardener
Security guard
Caretaker
(Other)

3b

(Please state the relevant option) / YES / No / Not for all
Do you have an employment contract with each staff member?
Is there a succession plan to replace each staff in the event they leave?
Do you have a staff development plan?

4. GOVERNANCE

(Please state Yes/ No) / YES / NO
Do you have an annual budget?
Do you have an annual work plan? (Goals, activities)?
Do you have a long-term (2 or 3 yr.) business plan?
Do you have policies and procedures in place?

5. SKILLS NEEDED BY YOUR ORGANISATION

Please tick what organisational skills your staff need. Add any skills not listed

Type of skill / Required / No of staff requiring training
Computer literacy
Home-based care - basic
Home-based care - advanced
HIV/AIDS management
Palliative care
TB training
HCT
Counselling
Financial management
Fundraising
Governance
Reporting to funders
Budgets
Writing a work plan
Monitoring and evaluation
Running a support group
Management of staff
Medical refresher courses
(other)

6. CATHCA and your organisation

a. What do you think CATHCA’s task is? (Select the THREE most important)

Help you get assistance from government
Provide useful information
Bring people in Catholic health care together
Facilitate discussions on important health issues
Assist you with spiritual support
Self-generated funds

7. (We use this information for funding proposals.Please tick on relevant challenges – place them in order of importance, 1 being the most serious challenge, etc))

a. What are the biggest challenges in your work?

Lack of Stipends / No funds for transport
Lack of operational cost funding / Lack of training
Lack of co-operation from Diocese/Parish / Lack of carers
Lack of Staff / Unregistered Health professionals
Lack of equipment / Lack of Office staff

b.What equipment or resources do you need? (Please tick those you mostly need)

Food packs / Transport money
HBC kits / Umbrellas
Medical Equipment / Garden tools
Uniforms/ Shoes / Others:
Salaries and Administration
  1. YOUR FUNDING/ INCOME GENERATING ACTIVITIES

a. Please list your current funders.

FUNDER / Activities funded / Amount(2015) / Activities funded IN KIND (specify)
  1. National Department of Health

  1. Provincial Department of Health

  1. Department of Social Development

  1. Other Government Department

  1. Local Funder/s

  1. Overseas funder/s

  1. Diocese

7. Other( please list)

b. List your income-generating activities?

Income Generating Activities / Amount per annum (R0.00)
  1. YOUR COMMUNITY: What relationship do you have with your community?

(Please tick those you have a relationship with)

Local Schools / Department of Health
Local Churches / Department of Home affairs
Local NGOs / Others:
Traditional leaders

b. If the district health department know you, what do they do and what do you do?

(Please tick only relevant items)

(Please tick below what they do) / (Please tick below what you do)
Ask us to do work for them occasionally (HCT, adherence monitoring) / We invite them to our meetings
Invite us to participate in health campaigns / We invite them to our AGMs
Provide us with gloves, masks or other equipment / We send to the community leaders our reports
Refer patients to us through the clinics / We put our work information in newsletters
Accept patients we refer to them / We appoint community meetings with leaders
Attend some of our meetings as NGOs / We go to schools to speak about us
Motivate support for us from government (provincial, national) / Ask for advice from community leaders
Other: / Others:
  1. Your relationship with the local Health Department (The most important part of this questionnaire!)
  1. What is your nearest government clinic?

How far away is it from you in kms?

  1. How good is your relationship with your district health manager?

(Please tick one)

We know each other well / They know us but not well / We do not know each other
  1. How often do you attend meetings with your district health manager and your local government clinics?

District health office / Local govt clinic
Weekly
Monthly
Annually
Never

Dear everyone

CATHCA has filed information on Catholic health care organisations and individuals, based on what you have given us over the years. With POPI now coming into action we need to ask your permission to use this information.

What is POPI?

It’s the Protection Of Personal Information Act 2013. It’s a law designed to prevent the negligent disclosure of personal information.

What this means is that an organisation or “responsible party” can only capture, use and store your personal information with your express consent.

What sort of personal information?

The definition of personal information includes anything that can be used to identify you in any way, your name, ID number and address, your religious affiliation, sexual orientation, medical history, criminal record, educational and financial history and even your biometric data, online identifiers (like say, a twitter handle)and location services. It also includes things like your personal opinions, any private correspondence and other people’s views about you.

Organisations that ask for information will be responsible for ensuring that it’s kept up to date. They also have a responsibility to take reasonable security measures to secure that information from the moment it’s been captured until it’s been destroyed.

What does this mean for me or my organisation?

We are talking here about personal Information – not the information on the organisation. This could be our learner records, from training we have done, or our individual Member database, or your personal email address or cell phone number.

By signing this page you give CATHCA permission to: (tick one option)

Share this information with other interested parties (eg government, funders, other NGOs, CATHCA members, etc)

Ask me first before sharing (N.B this may lead to delays if we cannot reach you quickly)

Do not share my information- this is only for CATHCA

NAME SIGNATURE

DESIGNATION DATE

Thank you for helping us with this information!

Please return to CATHCA as soon as possible

CATHCA OFFICES

Offices are at:
Room 7, The Haven
St Vincent’s School
off Tottenham Road
Melrose / Postal Address is:
CATHCA
P O Box 52015
SAXONWOLD
2132 / Contact information is:
Telephone: 011-880-4022
Fax: 011-880-4084
Email:
Website:

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