Survey for Administrators of Publicly-funded Health Cent

Form Approved

OMB Number: 0920-XXXX

Exp. Date: XX/XX/XXXX

2012-2013 SURVEY FOR ADMINISTRATORS OF

PUBLICLY-FUNDED HEALTH CENTERS THAT PROVIDE FAMILY PLANNING

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).

1. Health Center Characteristics

1.	What type of organization is your health center? (Please select one)
Health department (local, county, state)
Hospital
Planned Parenthood
Federally-Qualified Health Center (e.g. community health center)
Private, non-profit organization
Other (please specify)______________

2.	What best describes your health center’s clinical focus?
	Family planning/reproductive health
	Primary (general health) care
	Other (please specify) _____________

3.	What state or territory is your agency located in? _____________________

4.	Which best describes the area that your health center serves?
	Mostly urban/suburban
	Mostly rural
	Combination or rural & urban

5.	Approximately how many clients received any clinical services at your health center in the last year? (fiscal or calendar)
	< 500
	500 -999
	1,000-4,999
	5,000-9,999
	10,000 – 49,000
	50,000 +

6.	Approximately how many clients received family planning services at your health center in the last year? (fiscal or calendar)
	< 500
	500 -999
	1,000-4,999
	5,000-9,999
	10,000 +

7.	What is the approximate age and gender breakdown of your health center’s family planning clients?
	All clients (male and female)
		< 20 years old	______%
		20-29 years old	______%
		30-44 years old	______%
		45 years or older	______%
	Males (all ages)		______%

9.	Is your health center a part of the following health care networks?
		Yes	No	Don’t know
	Accountable care organization
	Medical home (PCMH or other)
	Medicaid managed care
	Other managed care network/PPO
	Participating provider in one or more private insurance company networks

II.	Questions about survey completion
10.	Which of the following best describes the primary role of the person or persons who completed this survey? (Select all that apply.)
	Administrator
	Medical director
	Nurse/nurse practitioner manager
	Other (please specify)__________

11.	If your health center is a part of a multi-site agency, did you consult your parent agency to complete this survey? (Select one.)
	Yes, parent completed entire survey
	Yes, parent completed or checked parts of the survey
	No, parent did not help complete or check the survey
	No, we are not part of a multi-site agency
	No, we are the parent agency

III.	Clinical Services Provided
12.	In the past 3 months, about how often did your health center provide the following services?
		Never	Rarely	Occasionally	Frequently
	Pregnancy diagnosis & counseling
	Contraceptive services for women
	Contraceptive services for men
	Basic infertility services for women
	Basic infertility services for men
	STD screening for women
	STD screening for men
	Preconception health care for women
	Preconception health care for men

13. In the past 3 months, were the following contraceptive methods* provided on site to clients who requested them? Also, please note whether your health center ran out of supplies of that method in the last 3 months.
	Provided on site, last 3 months			Supplies ran out, last 3 months
	Yes, to all clients who requested it	Yes, to some clients who requested it	No	Yes	No
Sterilization (male)
Sterilization (female)
LNG-IUD (Mirena®)
Cu-IUD (ParaGard®)
Implant (Implanon® or Nexplanon®)
DMPA (Depo-Provera®)
Patch (Ortho Evra®)
Vaginal ring (NuvaRing®)
Combined Oral Contraceptives (COCs)
Progestin-only oral contraceptives
Emergency contraceptive pills
Male condom
Female condom
*Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

14.

In the past 3 months, how often did your health center use the following referral practices?

Never

Rarely

Occasionally

Frequently

Provided a resource listing or directory to the client

Provided a documented referral to the client

Made an appointment for the client

Contacted the client directly about the referral outcome

Contacted the referral source to find out if the client was seen

Asked the client about the referral at his or her next visit

15.

The following questions refer to your health center’s clinical recommendations for on site, routine screening during initial or follow-up family planning visits. By screening, we mean the process of routinely asking questions about a client’s history or performing a physical exam or laboratory test in average-risk asymptomatic persons to help assess risk factors for, or the presence of, a specific disease or condition.

Is this standard of care for female clients?

Is this specified in a written protocol?

Is this standard of care for male clients?

Is this specified in a written protocol?

Yes

No

Yes

No

Yes

No

Yes

No

Intimate partner and sexual violence

Substance abuse

Tobacco use

Depression

Immunizations

Unhealthy diet

Body-mass index (BMI)

High blood pressure

Diabetes

High cholesterol

Chlamydia

Gonorrhea

Syphilis

HIV

Breast cancer

Cervical cancer

Testicular cancer

16.

The following questions relate to your health center’s clinical recommendations for contraceptive counseling.

Is this standard of care?

Is this specified in a written protocol?

Yes

No

Yes

No

Use open-ended questions

Assess the client’s reproductive life plan (i.e., ask about their intentions regarding the number and timing of pregnancies in the context of their personal values and life goals)

Presented information regarding potential contraceptive methods with the most effective methods presented first (tiered approach)

Help the client think about potential barriers to using their selected method correctly and develop a plan to deal with these barriers

Use method-specific consent forms

Inform adolescents that long-acting reversible contraceptives are safe and effective options

IV.	Health Center Infrastructure, Systems, and Community Education
17.	In the past 3 months, about how often did your health center make available the following services or materials to clients?
		Never	Rarely	Occasionally	Frequently
	Same-day appointments for clinical services
	Weekend or evening hours for clinical services
	Adolescent-only hours or days for clinical services
	Educational materials (written or video) specifically designed for adolescents
	Educational materials (written or video) in languages that match the needs of your client base
	Language translation services that match the needs of your client base
18.	In the past 3 months, about how often did your health center do the following, related to adolescent clients?
		Never	Rarely	Occasionally	Frequently
	Offered time alone with a provider for adolescents who come with a parent or guardian
	Required parental consent, for adolescents seeking contraceptive services
	Actively encouraged communication between adolescents and parents/guardians about sex and reproductive health
	Actively promoted the availability of confidential services to adolescents
19.	Does your health center use the following technologies?		No	Yes: Limited use	Yes: Routinely
	Electronic health records
	Electronic system for billing
	Email, phone, or text messages to clients for appointment reminders
	Email, phone, or text messages to clients for test results (e.g., STD)
	Website that allows clients to make appointments online

20. In the past 12 months, did your health center use any of the following methods for community education? (Not exclusively related to fund-raising)				21. In the past 12 months, did your health center conduct community education in the following places or groups?
	Yes	No			Yes	No
TV				Schools
Radio				Colleges or universities
Websites or social media (e.g. Facebook)				Other youth-serving groups
Billboards				Parent groups
Newspapers or magazines				Faith-based organizations
Community events				Other health care services
Small group education (1 session)				Community health fairs
Small group education (2+ sessions with same group)				Other social service organizations

V.	Quality improvement
22.	How often does your health center formally review the following aspects of service delivery, to monitor the quality of family planning services? (They could be measured in various ways.)
		Monthly or Quarterly	Annually	Every 2-3 years	As needed	Other frequency	Never/ not currently reviewed
	Availability of contraceptive methods
	Access to services
	Clinic efficiency
	Client satisfaction
	Cultural competency
	Referrals and/or care coordination
	Contraceptive use
	Cost of providing services
	Unintended pregnancy
	Birth spacing

23.	In the past 12 months, has your health center modified any clinical practices or other aspects of the health center, in response to a review of quality improvement data? Please note this question does not relate to any modification, but only those implemented in response to your center’s review of quality improvement data.
		Yes	No
	If yes, please briefly describe what aspect of service delivery was changed:

VI.	Referral Arrangements and Staff Training
24.	What kinds of partnerships does your health center have with providers who offer the following contraceptive methods and other services? (In each column, select all that apply.)
		We offer this on site	Co-located with those who do, or our parent organization provides this	Contract, or other written agreement	Informal relationships with provider(s) who do this	Referral only
	Female sterilization
	Male sterilization
	IUD insertion/removal
	Implant insertion/removal
	Natural family planning
	HIV treatment
	Prenatal care
	Primary care
	Infertility treatment
25.	Please indicate whether all, some, or none of the health center’s staff have received training in the following areas:
Trained in past 2 years: All relevant staff				All staff	Some staff	No staff
	Contraceptive counseling
	Serving male clients
Ever trained: Clinical staff only
	Inserting and removing copper IUD
	Inserting and removing hormonal IUD
	Inserting and removing contraceptive implants

Thank you for your time!

Please add any additional comments here:

Please mail the completed survey back or complete it online at:

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