Form 1 Training Survey for Health Organizations

TRAINING SURVEY

For Health Organizations

Thank you very much for joining us! We would like to ask you a few questions about your experiences as a health care provider, administrator, receptionist or patient liaison at a health care organization.

As you know, lifetime exposure to violence is associated with multiple poor health outcomes, and is likely to impact the lives of many of the clients you work with and counsel. We are developing strategies for incorporating questions about domestic and sexual violence, and reproductive and sexual coercion (DSV and RSC) into current protocols. We want to get your feedback about talking to your clients about exposure to DSV and RSC.

Please take a few moments to answer the following questions. Your responses are anonymous. You may skip any questions that you do not want to answer, and can stop taking the survey at any time.

We would also like to contact you in a few months to find out how useful this training was to you in practice, whether you were able to use any of the components presented, and to have you reflect on additional training, resources, and supports you want to see.

We greatly appreciate your taking the time to answer these questions for us as we aim to improve the violence prevention and intervention trainings for health care providers in health settings.

Date: _____________________________ Site: _____________________________________________

IF YOU ARE NOT PROVIDING DIRECT CARE TO CLIENTS, PLEASE SKIP TO QUESTION 8.

		All of the time 100%	Most of the time 75% or more		Some of the time 25% - 75%	Not so often 10% - 25%	Rarely Less than 10%	N/A
	How often do you:
1.	Talk to your patients about domestic and sexual violence (DSV)?
2.	Talk to your patients about reproductive and sexual coercion (RSC)?
3.	Review the limits of confidentiality with your clients before asking about DSV or RSC?
4.	Assess clients’ safety and discuss ways to stay safe in an unhealthy or abusive relationship?
5.	Refer clients to your DV partner organization?
6.	What are reasons that you may not address domestic and sexual violence (DSV) and reproductive and sexual coercion (RSC) during a clinic visit? (mark all that apply)
	Not enough time The partner is present for the visit Worried about upsetting the client Not sure what to say if they disclose an abusive/ violent relationship Not sure how to ask questions without seeming too intrusive			Not knowing where to refer them to Worried about mandated reporting Have already screened them at past visit Does not apply to my patient population Other (please specify):

Public Burden Statement: 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. The OMB control number for this project is 0915-0212. Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.

7.	How confident are you in referring a client to your partner organization? Completely confident Somewhat confident Not at all confident Not Applicable
8.	Does your clinic/practice have: (mark all that apply) Brochures, cards or information about DSV and RSC Posters about DSV and RSC displayed A list of violence-related resources and who to call with questions Prompts inserted into charts to remind providers to assess for DSV and RSC In-service trainings for all clinic staff on DSV and RSC Other (please specify):
9.	Are educational materials available on domestic and sexual violence (DSV) and reproductive and sexual coercion (RSC) in the languages most commonly spoken in your setting? Yes No Not applicable Don’t know
10.	Are the available materials on DSV and sexual coercion inclusive of diverse relationships including for sexual minorities, LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) clients? Yes No Not applicable Don’t know
11.	Optional: Please answer the following question. This information will help us better understand who we are reaching with these trainings. What is your training background? (mark all that apply) Reproductive health specialist/family planning counselor Promotora or community health worker Nurse practitioner (specify specialty area _________________) Physician assistant (specify specialty area _________________) Nurse (specify specialty area _________________) Physician (specify specialty area _________________) Clinic administrator/Practice manager Other _______________________________
Any Additional Comments?

Thank you for your time!

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