Form Approved:
OMB No.: 0920-XXXX
Expiration Date:
Sexually Transmitted Infection Services at U.S. Colleges and Universities
Attachment 3: College Survey
Public reporting burden of this collection of information is estimated to average 45 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-New)
NATIONAL SURVEY OF U.S. COLLEGES
This survey should be completed by the person at your academic institution who has the most knowledge of and access to information about health services. The questionnaire will take approximately 35-50 minutes to complete. Make sure to answer all questions, and to mark in the ‟don’t know/Not Applicable (NA)” columns if information is not available to you.
Name of school:_______________________________________ Today’s date _____/_____/_____
Name of respondent completing this questionnaire ____________________________________________________________
Job title of respondent _________________________________________
Phone: ( ) _____-__________ Fax ( ) _____-__________ E-mail:___________________
Is your school a member of the American College Health Association?
☐Yes
☐No
☐Don’t
know/NA
Student Health Insurance
Does your school have a ‟student health fee” for undergraduate students (check ‘yes’ even if the fee is not mandatory or if it is part of tuition-and-fees paid by the student)?
For full-time U.S. students
☐Yes ☐No ☐Don’t know/NA
For part-time U.S. students
☐Yes ☐No ☐Don’t know/NA
For international students
☐Yes ☐No ☐Don’t know/NA
Does the ‟student health fee” cover:
Testing symptomatic students for sexually transmitted infections (STI’s)?
☐Yes ☐No ☐Don’t know/NA
Screening asymptomatic students for STI’s?
☐Yes ☐No ☐Don’t know/NA
Is health insurance coverage mandatory for undergraduate students at your school (in addition to, or independent of, a ‟student health fee”)?
For full-time U.S. students
☐Yes ☐No ☐Don’t know/NA
For part-time U.S. students
☐Yes ☐No ☐Don’t know/NA
For international students
☐Yes ☐No ☐Don’t know/NA
What overall percentage of all students (part and full-time) have some form of health insurance (please give us your best estimate)? _______%
Does your college sponsor/provide its own health insurance plan?
☐Yes ☐No ☐Don’t know/NA
If no or don’t know, skip to question 18.
Does the college insurance plan offered by your school cover…
Testing symptomatic students for sexually transmitted infections (STI’s)?
☐Yes ☐No ☐Don’t know/NA
Screening asymptomatic students for STI’s?
☐Yes ☐No ☐Don’t know/NA
What overall percentage of students (part and full-time) is on the college-sponsored plan?
(Please give us your best estimate) ______________%
Are you aware of any patients who seek STI services at a service site other than your clinic to avoid high deductibles or co-pays they consider cost prohibitive?
☐Yes ☐No ☐Don’t know/NA
How does your health center address confidentiality issues around STI/HIV screening for students who are concerned that it will show up on an explanation of benefits (EOB)received by their parents? [open ended]
Preventive Services
How does your school provide education about HIV and AIDS?
Yes No Don’t know/
NA
Flyers/pamphlets/newsletters ☐ ☐ ☐
Posters ☐ ☐ ☐
Lectures as part of college classes ☐ ☐ ☐
Health fairs ☐ ☐ ☐
One-on-one education in health center ☐ ☐ ☐
School affiliated social media ☐ ☐ ☐
(e.g., Facebook, Twitter, Pinterest)
Peer education ☐ ☐ ☐
Part of orientation presentation ☐ ☐ ☐
Part of written orientation material ☐ ☐ ☐
School web page ☐ ☐ ☐
Watch parties (video presentation) ☐ ☐ ☐
Testing event ☐ ☐ ☐
Awareness or testing campaign ☐ ☐ ☐
(e.g. Sex Week, GYT)
Other:_____________________________________________________________
How does your school provide education about STI’s or STDs?
Yes No Don’t know/ NA
Flyers/pamphlets/newsletters ☐ ☐ ☐
Posters ☐ ☐ ☐
Lectures as part of college classes ☐ ☐ ☐
Health fairs ☐ ☐ ☐
One-on-one education in health center ☐ ☐ ☐
School affiliated social media ☐ ☐ ☐
(e.g., Facebook, Twitter, Pinterest)
Peer education ☐ ☐ ☐
Part of orientation presentation ☐ ☐ ☐
Part of written orientation material ☐ ☐ ☐
School web page ☐ ☐ ☐
Watch parties (video presentation) ☐ ☐ ☐
Testing event ☐ ☐ ☐
Awareness or testing campaign ☐ ☐ ☐
(e.g. Sex Week, GYT)
Other:_____________________________________________________________
How are condoms made available to students at your school? (check all that apply)
Free in open display ☐
Free upon request ☐
Nominal fee ☐
Vending machine ☐
Student health or wellness center ☐
Resident Halls ☐
Student Union ☐
Special events ☐
No condoms are available on campus ☐
Other:______________________ ☐
Does your school have a Student Health Center which provides health services to students?
☐Yes ☐No ☐Don’t know/NA
Does your school have a Wellness Center which provides health services to students
☐Yes ☐No ☐Don’t know/NA
Is your Wellness Center integrated with your Student Health Center?
☐Yes, they are combined programs
☐No, they are separate programs or we only have one
☐We do not have a Student Health Center or Wellness Center
If c, skip to question 33.
Health Services Information
On average, how many students visit the health/wellness center per month?
(Please give your best estimate) _____________
Do you have weekend hours for patients?
☐Yes ☐No ☐Don’t know/NA
Do you offer evening hours (or extended hours) for patients?
☐Yes ☐No ☐Don’t know/NA
Are students able to book appointments online?
☐Yes ☐No ☐Don’t know/NA
Are students able to contact a doctor or nurse via an online patient portal or other online method?
☐Yes ☐No ☐Don’t know/NA
Do you have an electronic medical records system that is used by the health centers staff?
☐Yes ☐No ☐Don’t know/NA
Which of the following professional staff work at the student health center?
Full-time Part-time No Don’t know/NA
Health educator ☐ ☐ ☐ ☐
Nurse practitioner ☐ ☐ ☐ ☐
Nurse (RN, LPN) ☐ ☐ ☐ ☐
Physician (any specialty) ☐ ☐ ☐ ☐
Physician Assistant ☐ ☐ ☐ ☐
Laboratory professional ☐ ☐ ☐ ☐
Mental Health provider ☐ ☐ ☐ ☐
Other: ☐ ☐ ☐ ☐
The student health center is primarily run/administered by a:
☐ Nurse
☐ Nurse Practitioner
☐ Physician
☐ Physician’s Assistant
☐ Health care administrator (MBA, MMM, etc.)
☐ Other: _________________
Which of the following services are available to students at the student health center?
Yes No Don’t know/NA
Health education ☐ ☐ ☐
Diagnosis and/or treatment of STI’s ☐ ☐ ☐
OB/GYN services ☐ ☐ ☐
Contraceptive services (e.g. family planning clinic) ☐ ☐ ☐
Long Acting Reversible Contraceptives (e.g. IUD) ☐ ☐ ☐
Emergency Contraception ☐ ☐ ☐
Pregnancy Testing ☐ ☐ ☐
Patient-delivered partner therapy for any STI ☐ ☐ ☐
Triage/referral to other clinics ☐ ☐ ☐
Rx dispensing ☐ ☐ ☐
Who primarily offers STI services on your campus?
☐ Student Health Center
☐ Wellness Center
☐ Local Health Department
☐ Outside organization (other than the health department)
☐ I don’t know
If c, d, or e, skip to Referral questions page.
Services for Sexually Transmitted Diseases
Does the student health center screen and/or test students for any STI (including HIV)?
☐Yes ☐No ☐Don’t know/NA
If Yes, skip to question 36.
Please identify possible reasons why the student health center does not evaluate students for STI’s.
Yes No Don’t know/NA
a. No or insufficient qualified staff. ☐ ☐ ☐
b. Time constraints of existing staff. ☐ ☐ ☐
c. Not covered by student health insurance. ☐ ☐ ☐
d. Conflicting with core principles of the institution. ☐ ☐ ☐
e. No perceived need. ☐ ☐ ☐
f. Close proximity to public STI clinic. ☐ ☐ ☐
g.Other:________________________________________________________________________
Skip to Referral Page
What type of lab do you contract with to conduct your STI testing (not including HIV)? (check all that apply)
☐ Commercial Lab (Labcorp, Quest)
☐ Public Health Lab
☐ In-house
☐ Community clinic or hospital lab
☐ Other: ___________________
What type of lab do you contract with to conduct your HIV testing (not including STI’s)? (check all that apply)
☐ Commercial Lab (Labcorp, Quest)
☐ Public Health Lab
☐ In-house
☐ Community clinic or hospital lab
☐ Other: ___________________
Which of the following statements best describes how the cost of STI screening is covered at your health service (choose one)
☐ All tests/visits are charged to the patient or their insurance (there is always a cost to the patient or their insurance)
☐ Some tests/visits are charged but others are free (there is sometimes a cost to the patient or their insurance)
☐ All tests/visits are free to the student (there is never a cost to the patient or their insurance)
☐ None of the above or not applicable
☐ Other:_______________________
Do you offer “express” testing for STI’s? (testing without counseling or seeing a physician)?
☐Yes ☐No ☐Don’t know/NA
Do you offer routine STI screening for asymptomatic men and women?
☐Yes ☐No ☐Don’t know/NA
Partner Management
How does your health center manage notification of sex partners of infected students (i.e., informing sex partners of infected students that they have been exposed to an STI and advising them to seek care)?
Ask the student to notify their partner(s)
Health services staff notify partners and arrange evaluation or treatment
Refer the case to the health department only (no other follow up)
Health center staff do not take any action on partner notification
Don’t know
If a, c, d or e are selected, skip to question 44.
For which STI’s:
☐Chlamydia
☐Herpes Simplex Virus
☐Gonorrhea
☐HIV/AIDS
☐Trichomoniasis
☐Hepatitis B
☐Syphilis
Are partner testing and treatment provided only to those partners who are students at the school themselves?
☐Yes ☐No ☐Don’t know
In the state in which your health center is located, is expedited partner therapy (EPT, also known as patient-delivered partner therapy) legal for STIs?
EPT is legal for at least one STI
EPT is of uncertain legality
EPT is not legal for any STI
I don’t know
Expedited partner therapy (EPT) is the practice of allowing infected patients to bring single-dose oral medications (or prescriptions) for chlamydia or gonorrhea to their sex partners before seeking evaluation.
HIV & STI testing
Which of the following STI’s are screened for in asymptomatic students (check all that apply)?
☐Chlamydia
☐Herpes Simplex Virus
☐Gonorrhea
☐HIV/AIDS
☐Trichomoniasis
☐Hepatitis B
☐Syphilis
☐None
☐Other:
Does the student health center offer testing for HIV?
☐ Yes ☐ No ☐ Don’t know
If no or don’t know, skip to question 49.
If yes, which kind of HIV testing is offered?
anonymous
confidential
both anonymous and confidential
What types of HIV antibody tests do you offer? (check all that apply)
☐Standard test, blood
☐Standard test, oral fluid
☐Rapid test, blood
☐Rapid test, oral fluid
☐None
☐Other: ________________
Do you routinely screen sexually active women under age 25 for chlamydia infection?
☐Yes ☐No ☐Don’t know/NA
If no or don’t know, skip to question 54
For patients who test positive for chlamydia, do you provide patient follow-up testing for chlamydia reinfection?
☐Yes ☐No ☐Don’t know/NA
Does the clinical laboratory providing diagnostic services use nucleic amplification tests to detect chlamydia?
☐Yes ☐No ☐Don’t know/NA
What type of specimen is usually/preferentially collected for chlamydia testing in women?
Cervical swab
Vaginal swab
Urine
Varies
None
Does your health center offer female patients the option of a self-collected vaginal swab?
☐Yes ☐No ☐Don’t know/NA
Does the student health center offer testing for gonorrhea?
☐Yes ☐No ☐Don’t know/NA
If no or don’t know, skip to question 60
What is the standard treatment used in your health center for positive cases of gonorrhea?
Ceftriaxone plus Azithromycin or Doxycycline
Ceftriaxone alone
Other cephalosporins
Quinolone
Azithromycin
Doxycycline
Amoxicillin
Other antibiotic (s)
Referred
out
Do you include pharyngeal tests for gonorrhea when screening men who have sex for men (MSM) for STIs?
☐Yes
☐No
☐N/A
Do you include rectal tests for gonorrhea and chlamydia when screening MSM for STIs?
☐Yes
☐No
☐N/A
What is the average time it takes for health services to receive a chlamydia/gonorrhea result from the laboratory?
< 24 hours
1 – 2 days
> 2 days
Would your health center be interested in a 90 minute (or less) chlamydia/gonorrhea diagnostic test?
☐Yes ☐No ☐Don’t know/NA
Does the student health center offer testing for trichomoniasis?
☐Yes ☐No ☐Don’t know/NA
Does the student health center offer serology testing for asymptomatic Herpes Simplex Virus?
☐Yes ☐No ☐Don’t know/NA
Is testing for syphilis routinely done during an evaluation for an STI?
☐ Yes ☐ No ☐ Don’t know ☐ only if risk factors identified
If no or don’t know, skip to question 64
What type of syphilis test do you use for routine screening?
RPR
VDRL
EIA
HPV Vaccine
Does the student health center offer HPV vaccine?
☐Yes ☐No ☐Don’t know/NA
If no or don’t know, skip to 69
Does the university’s student health insurance plan cover the cost of HPV vaccine?
☐Yes ☐No ☐Don’t know/NA
If no or don’t know, skip to 67
If yes, does coverage apply to:
☐ Females only
☐ Males and females
☐Don’t know/NA
Does the student health center provide reminders for doses 2 and 3?
☐Yes ☐No ☐Don’t know/NA
Which of the following groups are being offered HPV vaccination at the student health center?
Any male student 21 years or younger
☐ Yes ☐ No ☐ Don’t know
Any gay or bisexual male (or any man who has sex with men) student 26 years or younger, not previously vaccinated, requesting vaccination?
☐ Yes ☐ No ☐ Don’t know
Technical Assistance
We would like to understand what kind of help you receive from your local health department to support STI and HIV prevention activities on campus? Please select the best possible response to complete the following statement:
Our local health department provides greatest support in regard to:
☐ HIV screening and testing
☐ STI screening and testing
☐ Equal amount of support
☐ My local health department offers no support
What additional STI/HIV-related help would you like to receive from the health department? [open ended]
Skip to Referral Page
Referral Questions Page: For schools that do not provide on-campus services
Do you have a mechanism to refer students to off-campus health care providers?
☐Yes ☐No ☐Don’t know/NA
If no or Don’t know, skip to question 73.
What off-campus health care providers do you commonly refer students to for sexual health care? (check all that apply)
Community health center
Public health clinic
Family planning clinic
Private doctor’s office or HMO
Urgent care clinic
Other:__________________________
Skip to Last Page
What are the reasons for not having a mechanism to refer students to off-campus health care providers? (check all that apply):
No or insufficient qualified staff ☐
Time constraints of existing staff ☐
Lack of funds ☐
No perceived need ☐
Close proximity to public clinic ☐
Other:_______________________
Skip to Last Page
Last Page: Three Questions every participant will be ask
If there was an opportunity to partner with a federally qualified health center or community health center for sexual and reproductive health care, would you be interested in learning more?
☐ Yes
☐ No
If there was an opportunity to improve referrals for sexual and reproductive health care, would you be interested in learning more?
☐ Yes
☐ No
Please feel free to share any comments, thoughts, or questions you may have regarding this survey and/or college health services on your campus. [open ended]
After completion of survey, participants will see the following message:
You are now done with the survey. Thank you very much for your time and cooperation.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Becasen, JS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |