3 Advocate - Provider 6 Month Follow Up Survey for Health

6 MONTH FOLLOW UP SURVEY

For Health Organizations

Please take a few moments to answer the following questions referring back to the training you participated in several months ago on domestic and sexual violence (DSV) and reproductive and sexual coercion (RSC) in health settings.

Your responses will be kept confidential. You may skip any questions that you do not want to answer, and you can stop taking the survey at any time.

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 ITEM 12 ON THE REVERSE SIDE.

		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 partner organization?
6.	Since the training, I am more comfortable responding to clients who disclose abuse in their relationships. Strongly Agree Agree Undecided Disagree Strongly Disagree Not applicable
7.	Since the training, how confident are you in referring a client to your partner organization? Completely confident Somewhat confident Not at all confident Not Applicable
8.	Since the training, I am more comfortable helping and supporting a client to make phone calls to violence related agencies and services. Strongly Agree Agree Undecided Disagree Strongly Disagree Not applicable
9.	Since the training, has the frequency changed with which you are discussing healthy relationships? Increased since Stayed about the same Decreased since Not Applicable the training since the training the training

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.

10.	Since the training, has the frequency changed with which you are referring clients to local domestic violence/sexual assault resources? Increased since Stayed about the same Decreased since Not Applicable the training since the training the training
11.	Since the training, have you encountered more clients disclosing domestic and sexual violence (DSV) and/or reproductive and sexual coercion (RSC) experiences in the clinic? More disclosures About the same number Fewer disclosures than Not Applicable than before the training of disclosures before the training
12.	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):
13.	Since the training, has the frequency with which you meet with your local domestic and sexual violence related service providers changed? Increased since Stayed about the same Decreased since Not Applicable the training since the training the training
14.	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
15.	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
16.	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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