Patient Questionnaire

Attachment 3A Patient Questionnaire

Form Approved

OMB No: 0920-0840

OMB Exp. Date: 01/30/2019

Attachment 3A:

Patient Questionnaire

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0840).

Clinic User Survey – Administered to clinic users.

1. Is this your first time to this clinic?

[ ] Yes [ ] No

2. Do you feel that this clinic provides a welcoming and respectful environment?

[ ] Yes [ ] No [ ] Not sure

3. What are the reasons for your visit to this clinic today (choose all that apply)?

[ ] Health problem or symptoms

[ ] No health problems or symptoms, but came to get STD screening/check-up

[ ] Told to get checked by partner

[ ] Referred by health department/disease intervention specialist (DIS)

[ ] Follow-up visit

[ ] Came to get STD test results

[ ] Came to get HIV test

[ ] Came to get medication that I can take every day to prevent getting HIV infection before I am exposed to the virus (PrEP)

[ ] Came to get medication that I can take right away because I think I was exposed to HIV in the past few days (PEP)

[ ] Came to get contraception

[ ] Some other reason

Please specify ____________________

4. 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

Please specify ______________________

5. 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/ health department clinic

[ ] Family planning clinic

[ ] Private doctor’s office

[ ] Urgent care clinic/walk in clinic

[ ] Hospital emergency room (ER)

[ ] Hospital outpatient department

[ ] School-based clinic

[ ] Some other place

Please specify ________________________

6. Is there a place that you USUALLY go to when you are sick or need advice about your health?

[ ] Yes [ ] No  GO TO QUESTION #8

7. If YES, what kind of place do you go to most often (choose only one)?

[ ] Community health center

[ ] Public clinic/health department clinic

[ ] Family planning clinic

[ ] Private doctor’s office

[ ] Urgent care clinic/walk in clinic

[ ] Hospital emergency room (ER)

[ ] Hospital outpatient department

[ ] School-based clinic

[ ] Some other place

Please specify ________________________

8. Is there a place you USUALLY go to when you need routine care or preventive care such as a physical exam or check-up?

[ ] Yes [ ] No  GO TO QUESTION # 10

9. If YES, what kind of place do you go to most often (choose only one)?

[ ] Community health center

[ ] Public clinic/ health department 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

Please specify _____________________________

10. Do you have health insurance (choose only one)?

[ ] Yes, parents’ insurance plan

[ ] Yes, government (Medicaid, Medicare, etc.)

[ ] Yes, private insurance (through employer)

[ ] Yes, private insurance (purchased by yourself/healthcare.gov exchange)

[ ] No coverage of any type  GO TO QUESTION # 13

[ ] Don’t know  GO TO QUESTION # 13

11. If YES, would you be willing to use your health insurance for today’s visit?

[ ] Yes  GO TO QUESTION # 13

[ ] No

12. If No, why not (choose all that apply)?

[ ] I do not want my insurance company to know

[ ] Insurance company might send records home

[ ] I do not want my parents/spouse/significant other to know

[ ] Usual doctor might send records home

[ ] I cannot afford to pay the co-pay or deductible

[ ] My insurance will not cover this visit

[ ] Some other reason

Please specify __________________________________

13. What sex were you assigned at birth on your original birth certificate?

[ ] Male

[ ] Female

[ ] Refused

[ ] Don’t know

14. Do you currently describe yourself as male, female, or transgender?

[ ] Male

[ ] Female

[ ] Transgender

[ ] None of these

15. How old are you? Age in years______

16. What is your ethnicity?

[ ] Hispanic or Latino

[ ] Not Hispanic or Latino

17. What is your race (choose all that apply)?

[ ] American Indian or Alaska Native

[ ] Asian

[ ] Black or African American

[ ] Native Hawaiian or Other Pacific Islander

[ ] White

18. Which of the following best represents how you think of yourself?

[ ] Lesbian or gay

[ ] Straight, that is not lesbian or gay

[ ] Bisexual

[ ] Something else

[ ] I don’t know the answer

19. What is your current employment status (choose all that apply)?

[ ] Full-time employment

[ ] Part-time employment

[ ] Unemployed

[ ] Disabled

[ ] Student

[ ] Other

20. What is your highest level of school you have completed or the highest degree you have received ?

[ ] Middle school

[ ] Some high school

[ ] High school diploma

[ ] GED or equivalent

[ ] Some college

[ ] College degree or higher

21. What is the ZIP code where you live? ________

END CLINIC USER SURVEY