Youth Serving Organization (YSO) Organizational Assessme

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

YSO Organizational Assessment

Public reporting of this collection of information is estimated to average 1 hour 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)

Date Assessment completed: _________________________________________

Please provide the following information for your agency.

Agency Name
Mailing Address
City, State
Zip Code
Phone
Fax

Agency Type

School	☐
Community College	☐
Juvenile Justice/Probation/Court	☐
Social Service Agency (e.g., foster care)	☐
Behavioral Health Provider	☐
Youth-serving organization (e.g., YMCA, Boys and Girls club)	☐
Housing	☐
Other: ____________________________	☐

1. TEENS SERVED AND SERVICES PROVIDED

1. Please indicate the number of 15 to 19 year old youth served at your agency in the past year by race/ethnicity and gender.
	Number of Adolescent Clients (Unduplicated) Past Year
	Female	Male	Unknown
Hispanic/Latino – All Races1
Black or African American (Non-Hispanic)
White (Non-Hispanic)
Other (Non-Hispanic)
Unknown
Total

2. Please describe the types of services provided to teens at your agency.

2. Teen pregnancy prevention efforts

3. Is teen pregnancy prevention a priority of your agency’s work with teens?

☐ Not a priority

☐ Low priority

☐ Medium priority

☐ High priority

3. Is teen pregnancy prevention (please select all that apply):

☐ Included in your strategic plan?

☐ Included in efforts of an internal workgroup (i.e., group of staff that meets regularly)?

☐ Included in efforts of an advisory group (i.e., individuals from outside of your agency that meet regularly and provide guidance to your agency)?

☐ None of the above

Please indicate if your agency currently conducts any of the following activities:
		No	Yes
a	Distributes information or displays posters to youth focused on teen pregnancy prevention?	☐	☐
b	Conducts presentations to youth on sexual and reproductive health (SRH) or teen pregnancy prevention?	☐	☐
c	Provides counseling to youth on sexual and reproductive health?	☐	☐
d	Implements evidence-based teen pregnancy prevention intervention? (See http://tppevidencereview.aspe.hhs.gov/EvidencePrograms.aspx for a complete list)	☐	☐

3. If your agency implemented evidence-based teen pregnancy prevention program(s), please provide the following information in the table below.

Name of Program Implemented		Number of unique youth participating in the last 12 months	Age range of youth participants
1
2
3
4
5

3. Health Screening

Please indicate if your agency has written policies and procedures that address conducting a:
		No	Yes
a	Comprehensive health assessment1	☐	☐
b	Psycho-social screening	☐	☐
c	Screening to determine if a teen is in need of sexual and reproductive health services (e.g., is at risk for unwanted pregnancy or STI)	☐	☐

Definition: ¹Comprehensive health assessment includes a health history that includes past and present health issues, social history, and sexual history.

3. Please indicate which response(s) below best describes the frequency with which youth at your agency are screened to determine if they need a referral to sexual and reproductive health services (Check all that apply)

☐ Only once (e.g., at initial intake)

☐ At least annually

☐At each contact with youth

☐ Other ______________________________________________________

☐ Agency does not conduct sexual health screening (skip to question #12)

3. Please provide an estimate of the percentage of youth served by your agency who have been screened by your staff to determine if they need a sexual and reproductive health service. _____%

3. Please describe the process by which screenings to determine if youth are in need of sexual and reproductive health services are conducted at your agency (being sure to note the job titles of staff who conduct the screenings).

3. Are confidentiality procedures followed when conducting screening to determine need for sexual and reproductive health care? Confidential means the information shared by a patient or client is private and has limits on how and when it can be disclosed to a third party.

☐ No

☐ Yes

4. ReferralS and Linkages

Please indicate if your agency has written policies and procedures that address:
		No	Yes
a	Referrals for general health services?	☐	☐
b	Referrals for other social services such as behavioral health care, housing, food, or employment?	☐	☐
c	Referrals for sexual and reproductive health services?	☐	☐

3. Do staff at your agency provide referrals for sexual and reproductive health (SRH) services?

☐ Yes

☐ No (If no, skip to question #16)

Please indicate if your agency has written policies and procedures in place to conduct the following activities related to referrals for sexual and reproductive health services:
	NO	YES
Provide an up to date (in the past 12 months) directory or list of local youth friendly (i.e., delivery of health services based on the understanding of and respect for what young people want and need) sexual and reproductive health clinical services	☐	☐
Provide information on the clinic(s) most accessible and acceptable for the youth	☐	☐
Provide information and answer questions about what to expect at a sexual and reproductive health clinic visit	☐	☐
Make sexual and reproductive health (SRH) care appointments for the youth either by phone or online	☐	☐
Have youth make an appointment either by phone or online while the referring staff member is with the youth	☐	☐
Provide transportation assistance for youth to access SRH services	☐	☐
Contact the SRH referral source to find out if the youth was seen	☐	☐
Follow-up with youth to ask if they have made and kept SRH appointments based on the staff members’ referral	☐	☐

Please indicate how frequently staff at your agency conduct the following activities related to referrals for sexual and reproductive health services:
	Never	Rarely	Sometimes	Often	Always
Provide an up to date (in the past 12 months) directory or list of local youth friendly (i.e., delivery of health services based on the understanding of and respect for what young people want and need) sexual and reproductive health clinical services	☐	☐	☐	☐	☐
Provide information on the clinic(s) most accessible and acceptable for the youth	☐	☐	☐	☐	☐
Provide information and answer questions about what to expect at a sexual and reproductive health clinic visit	☐	☐	☐	☐	☐
Make sexual and reproductive health (SRH) care appointments for the youth either by phone or online	☐	☐	☐	☐	☐
Have youth make an SRH appointment either by phone or online while the referring staff member is with the youth	☐	☐	☐	☐	☐
Provide transportation assistance for youth to access SRH services	☐	☐	☐	☐	☐
Contact the SRH referral source to find out if the youth was seen	☐	☐	☐	☐	☐
Follow-up with youth to ask if they have made and kept SRH appointment based on the staff members’ referral	☐	☐	☐	☐	☐

Please indicate the extent to which each of the following is an issue with providing referrals for sexual and reproductive health services for staff at your agency:
	Not at all a problem	Minor problem	Moderate problem	Serious problem
Inadequate staff time to make sexual and reproductive health (SRH) referrals	☐	☐	☐	☐
Inadequate staff training on making SRH referrals	☐	☐	☐	☐
Staff members are not comfortable discussing issues related to SRH	☐	☐	☐	☐
Communication difficulties with SRH health center referral sites	☐	☐	☐	☐
Waiting lists at SRH referral sites are too long	☐	☐	☐	☐
Contact information for SRH referral sites is not readily available	☐	☐	☐	☐
Other: ______________________________ ___________________________________	☐	☐	☐	☐

3. Does your agency have a process in place for documenting youth referrals for SRH services (e.g., tracking the number of SRH referrals made; tracking referrals made in order to follow-up to determine if youth received services)?

☐ Yes

☐ No (If no, skip to question #19)

3. Please describe the process your agency uses for documenting youth referrals.

5. Staff Training and Capacity

Has your organization offered trainings/professional development opportunities in the past 12 months on the following topics for staff with contact with youth?
	No	Yes	Is Training Mandatory?	Frequency of Training?
Providing effective and confidential sexual and reproductive health (SRH) referrals including steps in making a SRH referral.	☐	☐	☐No ☐ Yes	☐ Upon hiring ☐ Annually ☐Other_____
Agency policies and protocols for making and tracking referrals	☐	☐	☐No ☐ Yes	☐ Upon hiring ☐ Annually ☐Other_____
Overview of adolescent sexual and reproductive health needs	☐	☐	☐No ☐ Yes	☐ Upon hiring ☐ Annually ☐Other_____
State laws related to minor’s rights to reproductive health care (including confidentiality)	☐	☐	☐No ☐ Yes	☐ Upon hiring ☐ Annually ☐Other_____
State requirements for reporting suspected child abuse	☐	☐	☐No ☐ Yes	☐ Upon hiring ☐ Annually ☐Other_____
Trauma informed approaches to working with young people (an approach that engages individuals with histories of trauma, recognizes the presence of trauma symptoms, and acknowledges the role that trauma has played in their lives).	☐	☐	☐No ☐ Yes	☐ Upon hiring ☐ Annually ☐Other_____
Needs of LGBTQ youth	☐	☐	☐No ☐ Yes	☐ Upon hiring ☐ Annually ☐Other_____

Please indicate the number of staff who:
		Number of Staff
a	Provide referrals to youth as part of their job duties?
b	Provide referrals to youth for sexual and reproductive health services as part of their job duties?
c	Have providing referrals for youth listed in their job description?

1 Count data for all clients that indicated Hispanic/Latino(a) ethnicity, regardless of race