Administrative Questionnaire

Attachment 3b: Administrative Questionnaire

Form Approved

OMB No: 0920-0840

OMB Exp. Date: 01/30/2019

Attachment 3B:

Administrative Staff Questionnaire

CDC estimates the average public reporting burden for this collection of information as 10 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).

Administrative Questionnaire – Completed by designated clinic staff person, one per clinic.

Clinic Billing

1. Do you currently bill health insurance or third party payers for services provided in this clinic? (choose only one)

[ ] Yes, we bill Medicaid only.

[ ] Yes, we bill private health insurance plans only.

[ ] Yes, we bill both Medicaid and private insurance plans.

[ ] No, we do not currently bill any health insurance plans or programs for services provided in this clinic.

2. Do you currently charge a fee for services provided in this clinic? (choose all that apply)

[ ] Yes, we charge a flat fee for services provided in this clinic.

[ ] Yes, we charge a sliding scale fee for services provided in this clinic.

[ ] Yes, we charge a fee based on the level and number of services provided in this clinic.

[ ] Yes, we charge a fee but it is waived if a person is unable to pay or if the patient is concerned about confidentiality

[ ] No, we do not charge for services provided in this clinic.

3. Is your clinic currently affiliated with any health system?

[ ] Yes, we are affiliated with a local health system or hospital.

[ ] Yes, we are part of the local public health system.

[ ] Yes, we are affiliated with a federally qualified health center (FQHC) or community health center (CHC).

[ ] No, we are a private, independent clinic.

[ ] Other, specify: ___________________________

Clinic Services

4. Can you estimate the number of visits seen per week in your clinic? (choose only one)

[ ] 1-25 visits per week

[ ] 26-50 visits per week

[ ] 51-99 visits per week

[ ] 100+ visits per week

5. Does your clinic have same day or drop-in appointments?

[ ] Yes [ ] No

6. If Yes, on average, what proportion of your visits are for same day or drop-in appointments (choose only one)?

[ ] 1-25% [ ] 26-50% [ ] 51-75% [ ] 76-100%

7. Does your clinic offer patient self-collection of specimens? This includes allowing patients to self-collect vaginal /pharyngeal/rectal swabs. (choose all that apply)

[ ] Vaginal [ ] Pharyngeal [ ] Rectal [ ] Not available

8. If your clinicians need a complex STD case clinical consultation, who do they contact (choose all that apply)?

[ ] Local ID SME (including local academic or medical school SMEs)

[ ] ID SME via telemedicine

[ ] STD Clinical Prevention Training Center Clinical Consultation Network

[ ] Other, specify: ____________________

[ ] Not sure

9. Does your clinic provide HIV pre-exposure prophylaxis (PreP) to patients? These are medications to prevent the spread of HIV before exposure to the virus. Check all that apply.

[ ] Yes, all medications, care, and management is provided in this clinic.

[ ] Yes, we start patients on therapy in this clinic and then refer them for ongoing management.

[ ] No, but referral provided for this service. Patients referred to: _______________________

[ ] No, not part of services offered at this clinic.

10. Do you have on-site injectable medications for the treatment of sexually transmitted infections (choose all that apply)?

[ ] Yes, Ceftriaxone IM (Rocephin)

[ ] Yes, Penicillin G benzathine IM (Bicillin L-A)

[ ] Gentamicin IM

[ ] No, we do not have on-site injectable medication for the treatment of sexually transmitted infections

11. Do you have other medications onsite for the treatment of sexually transmitted infections (choose all that apply)?

[ ] Azithromycin 1gm PO

[ ] Cefixime 400 mg PO

[ ] Doxycycline 100mg PO

[ ] Metronidazole 2g PO

[ ] Moxifloxacin 400 mg PO

[ ] Provider applied therapy for genital warts (cryotherapy, trichloroacetic acid, bichloroacetic acid, etc.)

12. Please check the diagnostic tests your clinic can perform while the patient waits for results (choose all that apply).

[ ] Qualitative RPR

[ ] Dark field microscopy

[ ] Other rapid syphilis test (e.g. Trinity Biotech Syphilis Health Check)

[ ] Rapid HIV test

[ ] Gram stain

[ ] Wet mount

[ ] Other, specify: _________________

13. Does your clinic provide literature addressing the sexual health needs and concerns of LGBT patients?

[ ] Yes

[ ] No