Form Approved
OMB No. 0920-0840
Expiration Date 02/29/2016
DSTDP Assessment of STD clinic users
Attachment 1
Clinic Survey
March 5, 2013
Public reporting burden of this collection of information is estimated to average 10 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 NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)
1. What are the reasons for your visit to this clinic today (choose all that apply)?
Health problem or symptoms
No health problem or symptoms, but came to get STD screening/check-up
Told to get checked by partner
Referred by the health department
Follow-up visit
Came to get STD test results
Came to get HIV test
Came to get contraception
Some other reason ____________________________
2. What is the main reason you chose this clinic for care (choose only one)?
Could walk in or get same day appointment
Cost
Privacy concern
Expert care
Embarrassed to go to usual doctor
Some other reason ____________________________
3. What is the next most important reason you chose this clinic for care (choose only one)?
Could walk in or get same day appointment
Cost
Privacy concern
Expert care
Embarrassed to go to usual doctor
Some other reason ____________________________
No other reason
4. Where would you have gone today if this STD clinic did not exist (choose only one)?
I would have waited to see how I felt and then decided what to do
Community health center
Public clinic
Family planning clinic
Private doctor’s office or HMO
Urgent care clinic/walk-in clinic
Hospital emergency room (ER)
Hospital outpatient department
School-based clinic
Some other place ____________________________
Not applicable
5. Is there a place that you USUALLY go to when you are sick or need advice about your health?
Yes
No
If YES, what kind of place do you go to most often (choose only one)?
Community health center
Public clinic
Family planning clinic
Private doctor’s office or HMO
Urgent care clinic/walk-in clinic
Hospital emergency room (ER)
Hospital outpatient department
School-based clinic
Some other place ____________________________
Don’t go to one place most often
6. Is there a place that you USUALLY go to when you need routine or preventive care, such as a physical exam or check-up?
Yes
No
If YES, what kind of place do you go to most often (choose only one)?
Community health center
Public clinic
Family planning clinic
Private doctor’s office or HMO
Urgent care clinic/walk-in clinic
Hospital emergency room (ER)
Hospital outpatient department
School-based clinic
Some other place ____________________________
Don’t go to one place most often
7. Do you have health insurance (choose only one)?
Yes, parents’ insurance plan
Yes, government insurance (Medicaid, Medicare, etc.)
Yes, private insurance
No coverage of any type
Don’t know
If YES, would you be willing to use your health insurance for today’s visit,
Yes
No
If NO, because (choose all that apply):
I do not want my insurance company to know
Insurance might send records home
I do not want my parents/spouse/significant other to know
Usual doctor might send records home
I cannot afford the co-pay/deductible
My insurance will not cover this visit
Other ____________________________
8. Are you male or female (choose only one)?
Male
Female
Male to female transgender
Female to male transgender
9. How old are you? Age in years _____
10. What is your ethnicity?
Hispanic or Latino
Not Hispanic or Latino
11. What is your race (choose all that apply)?
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaskan Native
12. Do you think of yourself as (choose only one)?
Heterosexual or straight
Homosexual, gay, or lesbian
Bisexual
13. What is your current employment status (choose all that apply)?
Full-time employment
Part-time employment
Unemployed
Disabled
Student
Other
14. What is the highest level of school you have completed or the highest degree you have received (choose only one)?
Middle school
Some high school
High school diploma
GED or equivalent
Some college
College degree or higher
15. What is the ZIP code where you live? __________
| File Type | application/msword |
| File Modified | 2013-03-05 |
| File Created | 2013-03-05 |