Youth Serving Organization (YSO) Staff Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

YSO Staff Survey

Public reporting of this collection of information is estimated to average 20 minutes/hours 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)

Thank you for agreeing to complete this survey. The purpose of this survey is to assess your job duties, knowledge, attitude, comfort level, and training related to referring youth at risk for teen pregnancy to health care services.

Your responses will be kept private and your completed assessment will be stored on a secure, password protected server. Your responses will be combined with those from others at your organization in order to tailor training and technical assistance. Your individual responses will not be shared. Your participation in this survey is voluntary and you can discontinue participation at any time.

1. BACKGROUND

Name of Organization
1.2 Current Position	Social Worker Case Worker Program Manager Youth Program Associate Family Support Specialist Counselor Health Educator Teacher Nurse Probation Officer Other ________________

2. JOB DUTIES

As part of your current job duties, how frequently do you:

	Never	Rarely	Sometimes	Often	Very Often
2.1 Provide referrals for any type of social service (e.g., housing, education, food)?
2.2 Provide referrals for any type of health care?
2.3 Provide information on how to prevent pregnancy?
2.4 Provide information on how to prevent STD/HIV?
2.5 Provide a referral guide for adolescent reproductive health services?
2.6 Conduct screenings to determine if a teen is in need of sexual and reproductive health services (e.g., is at risk for unwanted pregnancy or STI)?
2.7 Provide passive referrals for adolescent sexual and reproductive health services? In a passive referral, a client is provided with information about a service, such as a clinic name and location. It is then up to the client to access the service.
2.8 Provide active referrals for adolescent sexual and reproductive health services? In an active referral, a client is provided with assistance in getting the referral service, such as getting help setting up an appointment or finding transportation.

3. KNOWLEDGE AND ATTITUDES

How much do you agree or disagree with the following statements?

	Strongly Disagree	Disagree	Neither agree nor disagree	Agree	Strongly Agree
3.1 I know enough about sexual and reproductive health to talk to teens.
3.2 I am confident in my ability to discuss preventing STD/HIV and pregnancy prevention with teens in a non-judgmental way.
3.3 I am confident in my ability to conduct a 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).
3.4 If I talk to teens about sexual activity, STD, HIV and pregnancy this will encourage teens to have sex.
3.5 Teens that are sexually active should get information and referrals about sexual and reproductive health services regularly.
3.6 I am familiar with the different types of birth control, including IUDs and hormonal implants.
3.7 I am comfortable talking about sexual and reproductive health with lesbian, gay, bisexual, transgender, questioning, queer (LGBTQQ) youth.
3.8 It’s difficult for me to talk with teens about sexual and reproductive health because I believe teens should not be sexually active.

4. REFERRALS AND LINKAGES TO SERVICES

Adolescent sexual and reproductive health services includes services such as sexual health assessment, contraceptive services, pregnancy testing and counseling, health exams, STD screening and treatment, and HIV testing.

How much do you agree or disagree with the following statements?

	Strongly Disagree	Disagree	Neither agree nor disagree	Agree	Strongly Agree
4.1 It is important to my supervisor that I refer teens to sexual and reproductive health service when needed.
4.2 It is an important part of my job to refer youth to sexual and reproductive health services when needed.
4.3 I know my organization’s policies about how to provide and document a referral.
4.4 I know where to refer teens for youth-friendly, low or no cost, confidential sexual and reproductive health services.
4.5 I am confident in my ability to provide youth information and answer their questions about what to expect during a clinic visit during which sexual and reproductive health would be addressed.
4.6 I am confident in my ability to inform teens about their rights to confidential sexual and reproductive health services.
4.7 I am confident in my ability to provide teens with passive referrals for sexual and reproductive health services. In a passive referral, a client is provided with information about a service, such as a clinic name and location. It is then up to the client to access the service.
4.8 I am confident in my ability to provide teens with active referrals for sexual and reproductive health services. In an active referral, a client is provided with assistance in referral services, such as setting up an appointment, providing transportation, reminder call/text or email, or providing an incentive for clinic visit
4.9 I am confident in the quality of sexual and reproductive health services at the local health centers where I can refer youth.

6. TRAINING

Please indicate your training history and additional needs on the following topics.

Topic	Have you attended any workshop/Had training in the past year?	Would you like additional training?
6.1 Providing effective and confidential sexual and reproductive health (SRH) referrals including steps in making a SRH referral.	Yes No	Yes No
6.2 Agency policies and protocols for making and tracking referrals	Yes No	Yes No
6.3 Overview of adolescent sexual and reproductive health needs	Yes No	Yes No
6.4 State laws related to minor’s rights to reproductive health care (including confidentiality)	Yes No	Yes No
6.5 State requirements for reporting suspected child abuse	Yes No	Yes No
6.6 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).	Yes No	Yes No
6.7 Needs of LGBTQ youth	Yes No	Yes No

THANK YOU!