Helath Center Youth Survey

Performance Monitoring of “Working with Publicly Funded Health Centers to Reduce Teen Pregnancy among Youth from Vulnerable Populations

Att 6 Health Center Youth Survey_6 22 2016

Health Center Youth Survey

OMB: 0920-1156

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OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx














Health Center Youth Survey



































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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



  1. 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


  1. 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: _________________________

  1. Was it easy to make an appointment?

☐ No Yes

☐ I did not make an appointment.

If NO, what would make it easier? ______________________________________

______________________________________



  1. 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.

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



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

☐ No Yes



  1. Did the clinic staff treat you with respect?

☐ No Mostly Yes



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

☐ No Mostly Yes



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

☐ No Mostly Yes



  1. 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)



  1. 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



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

☐ No Yes









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

☐ No Yes



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

☐ No Yes



  1. Did you receive information today about birth control?

☐ No (Go to question 26)

☐ Yes



  1. 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



  1. 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.



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

☐ No Yes



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

☐ No Yes



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

☐ No (If NO, go to question 26)

☐ Yes











  1. 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: ______________________

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

☐ No Yes



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

☐ No Mostly Yes



  1. 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.



  1. 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.

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

☐ No Probably Yes, definitely



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

☐ No Probably Yes, definitely



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

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