Helath Center Youth Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Health Center Youth Survey

Public reporting of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current 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: PRA (XXXX-XXXX)

Youth Survey

This survey asks questions about your experience during today’s visit. This survey is voluntary. That means you do not have to take it. You also can answer some questions and not others. If you decide not to take the survey, it will not have an effect on the services that you get at this clinic. Your answers to these questions will be private. That means no one will know your answers. To help us keep your answers private, please do not write your name on this survey. Clinic staff refers to all staff you saw today –front desk staff, doctors, counselors and nurses.

1. Is this your first visit to this clinic?

☐No ☐Yes

2. How did you hear about this clinic? (Check all that apply)

☐ Friend

☐ Parent

☐ Other family member

☐ Adult at school

☐ Other adult: __________________

☐ Handout, flier, or poster

☐ Website

☐ Social media (Facebook, twitter)

☐ [add list of grantee outreach efforts]

☐ Not sure/been coming here for years

3. What caused you to come to the clinic today? (check all that apply)

☐ Sick or hurt

☐ Needed a check-up or a shot

☐ Seeking birth control

☐ Other: _________________________

4. Was it easy to make an appointment?

☐ No ☐Yes

☐ I did not make an appointment.

If NO, what would make it easier? ______________________________________

______________________________________

5. Is the clinic open at times that make it easy for you to come in for a visit?

☐ No ☐Yes

If NO, would you prefer the clinic was: (check all that apply)

☐ Open earlier

☐ Open later

☐ Open more weekend hours

The following questions are about your experience during today’s visit.

6. How long did you wait before seeing your doctor or nurse? _______ minutes

6a. Did you think this was too long to wait?

☐ No ☐Yes

7. Did the clinic staff treat you with respect?

☐ No ☐ Mostly ☐ Yes

8. Did the clinic staff listen carefully to what you had to say?

☐ No ☐ Mostly ☐ Yes

9. Did the clinic staff talk to you using words that you understood?

☐ No ☐ Mostly ☐ Yes

10. If you are 15 to 17 years old, did you have time alone with your doctor or nurse without your parent/guardian in the room?

☐ No

☐ Yes

☐ I’m 18 years or older (Go to question 12)

11. Did clinic staff tell you about your right to get sexual health care (for example, get birth control) without needing permission from a parent or guardian? ☐ No ☐ Yes

12. Did clinic staff tell you about the clinic’s rules about keeping your information private?

☐ No ☐ Yes

13. Did a doctor or nurse talk to you today about whether you are or have been sexually active?

☐ No ☐ Yes

14. Did you receive information today about preventing sexually transmitted infections?

☐ No ☐ Yes

15. Did you receive information today about birth control?

☐ No (Go to question 26)

☐ Yes

16. Did you get all of the information that you needed about your birth control options today?

☐ No

☐ Mostly, but I still had a few questions

☐ Yes

17. Did any staff person describe contraceptive implants or IUDs today?

☐ Gave a lot of information about implants and/or IUDs

☐ Mentioned implants and/or IUDs.

☐ Did not mention implants or IUDs.

18. Did you receive information about the importance of using a condom and birth control to prevent pregnancy and sexually transmitted infections?

☐ No ☐ Yes

19. Do you trust the information about birth control that you received today?

☐ No ☐Yes

20. During your visit today, did you choose a type of birth control?

☐ No (If NO, go to question 26)

☐ Yes

21. What type of birth control did you choose today? (Check all that apply.)

☐ Condoms

☐ Birth control pills, patch, or ring

☐ Shot (such as Depo-Provera)

☐ Implant (such as Implanon)

☐ IUD (such as Mirena or ParaGard)

☐ Other: ______________________

22. Have you used this type of birth control before?

☐ No ☐Yes

23. Did you feel you could freely choose the birth control you wanted today?

☐ No ☐ Mostly ☐ Yes

24. Who chose your method of birth control today?

☐ I chose the method.

☐ My doctor or nurse and I chose it together.

☐ My doctor or nurse chose the method.

25. Did clinic staff tell you that you could call or come back to the clinic if you have questions about your birth control?

☐ No ☐Yes

Thinking about your overall experience today, please answer the following three questions.

26. If you needed to see a doctor again, would you come back to this clinic?

☐ No ☐ Probably ☐ Yes, definitely

27. Would you tell your friends and others your age that they should come to this clinic?

☐ No ☐ Probably ☐ Yes, definitely

28. How can we make your next clinic visit better? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________