Survey of Administrators of Publicly-funded Health Cente

Form Approved
OMB Number: 0920-XXXX
Expiration 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 40 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).

I.

Health Center Characteristics

1.

What type of organization is your health center? (Select all that apply.)
Hospital
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Planned Parenthood
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Community health center
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Private, non-profit organization
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Other:_________________________
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2.

What best describes your health center’s clinical focus?
Family planning/reproductive health
Primary (general health) care
Other: _____________________________

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3.

What state or territory is your agency located in?
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4.

Which best describes the area that your health center serves?
Mostly urban/suburban
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Mostly rural
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Combination of rural & urban
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5.

II.
9.

6.

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

8.

Is your health center a part of the following health care networks?

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

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

No

Don’t
know

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Clinical Services Provided
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
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

Supplies ran out, last 3 months

Yes

No

Yes

No

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*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.

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10.

In the past 3 months, about how often did your health center provide the following services?
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

11.

Occasionally

Frequently

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Never

Rarely

Occasionally

Frequently

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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?
Intimate partner and sexual violence
Alcohol and drug use
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

13.

Rarely

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

12.

Never

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

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The following questions relate to your health center’s clinical recommendations for contraceptive counseling.
Is this standard
of care?
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)
Present 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
Page 2 of 4

Is this specified in a
written protocol?

Yes

No

Yes

No

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III.
14.

Health Center Infrastructure, Systems, and Community Education
In the past 3 months, about how often did your health center make available the following services or materials to clients?
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

15.

17.

Does your health center use the following technologies?
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
In the past 12 months, did your health center use any of the following
methods for community education? 
TV
Radio
Websites or social media (e.g., Facebook)
Billboards
Newspapers or magazines
Community events
Small group education (1 session)
Small group education (2+ sessions with same group)

IV.
19.

Occasionally

Frequently

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Yes

No

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18.

Never

Rarely

Occasionally

Frequently

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No

Yes: Limited use

Yes: Routinely

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In the past 12 months, did your health center conduct
community education in the following places or groups?
Schools
Colleges or universities
Other youth-serving groups
Parent groups
Faith-based organizations
Other health care services
Community health fairs
Other social service organizations

Yes

No

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Quality improvement
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.)

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
20.

Rarely

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In the past 3 months, about how often did your health center do the following, related to adolescent clients?
Offered time alone with a provider for adolescents who came 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

16.

Never

Monthly or Quarterly Annually Every 2-3 years As needed Other frequency Never/not currently reviewed

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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.

If yes, please briefly describe what aspect of service delivery was changed:

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❑ Yes

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V.
21.

Referral Arrangements and Staff Training
What kinds of partnerships does your health center have with providers who offer the following contraceptive methods and other services?
(In each row, select all that apply.)

Female sterilization
Male sterilization
IUD insertion/removal
Implant insertion/removal
Natural family planning
HIV treatment
Prenatal care
Primary care
Infertility treatment
22.

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

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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
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

VI.
23.

25.

All staff

Some staff

No staff

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Questions about Survey Completion and Awareness of Guidelines
Which of the following best describes the primary role of the
person or persons who completed this survey? (Select all that apply.)
Administrator
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Medical director
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Nurse/nurse practitioner manager
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Other (please specify) ____________________
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24.

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

How did you learn about the 2013 Guidance for Providing Quality Family Planning Services? (select all that apply)

I did not know about the guidelines before participation in this survey.
Conference attendance
Journals
Online resources
Parent agency
Professional organization publications or notifications
Other (please specify) __________________________________________

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Please share any additional comments that you may have in the space below.

Thank you for completing this survey!

Please return using the enclosed postage paid envelope.
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