Form Tab 4 Tab 4 Patient Exit Survey

Tab 4

Patient Exit Survey

Date (MM/DD/YYYY)

Month ___ ___ Day ___ ___ Year ___ ___ ___ ___

Study Site

Alabama-Birmingham Johns Hopkins

Boston Miami

Houston/Thomas St. SUNY Brooklyn

What is your gender? (choose one)

Male Transgender (male to female)

Female Transgender (female to male)

What is your race? (check all that apply)

Black or African American White

Asian Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

What is your ethnicity? (choose one)

Hispanic or Latino

Not Hispanic or Latino

1. At your clinic visit today, did any clinic staff person offer you the “Stay Connected” brochure about the importance of keeping all of your appointments at this clinic?

Yes (go to Question 3)

No (go to Question 2)

2. Did you receive the “Stay Connected” brochure at any previous visit to this clinic?

Yes

No

3. At your clinic visit today, did your health care provider (doctor, nurse practitioner, physician assistant, nurse) talk to you about the importance of keeping all of your appointments at this clinic?

Yes

No

4. At your clinic visit today, did anyone else talk with you about the importance of keeping all of your appointments at this clinic?

Yes

No