Survey of Administrators of Health Centers that provide

Form Approved
OMB Number: 0920-0969
Expiration Date: XX/XX/XXXX

2018–2019 SURVEY of ADMINISTRATORS of
HEALTH CENTERS THAT PROVIDE FAMILY PLANNING
Be assured that your responses will be maintained in a secure manner. This survey has been
approved by the Centers for Disease Control and Prevention as non-research public health practice.
Please return this survey within 21 days using the enclosed business reply mail envelope.

To determine if you are eligible to participate in this survey, please answer the following question:
Does your clinic provide family planning services* to at least two women of reproductive age per week?

Yes ❑ If you answered yes, please continue and complete the survey.
No ❑ If you answered no, you may stop here. Please return the survey in the envelope provided so we can
remove you from our list. Thank you for your time.
* For the purpose of this survey, a family planning service is any service related to postponing or preventing pregnancy. Family planning services may
include a medical examination related to provision of a method, contraceptive counseling, method prescription or supply visits. A patient may receive a
family planning service even if the primary purpose of the visit is not for contraception.

Please answer each of the following questions as they relate to the health center where you
are receiving this survey.
• You may need assistance from other staff, such as your site medical director, to complete this survey
• If you are a part of a multi-site agency, feel free to consult with your parent agency to answer
questions as needed or as may be required by your agency. However, most questions relate to this
specific clinic or center (not to the parent agency).
• If you work for an agency that oversees more than one clinic or center, please answer only for the
one center or clinic at which you received this survey.
• The information will not be used to assess compliance with federal or other regulations or as part of
your agency’s performance reviews.
• Your complete answers are essential to helping us support publicly-funded family planning service in
the future.
To complete the survey online, visit: www.insertwebsitehere.com

Only authorized users may complete the survey. The web survey is conducted from a secure https (SSL) service using the same type of internet security as is used for handling credit card transactions. If you
have any problems accessing or completing the survey, please contact [insert email here]. To access the survey:

Your username is: [insert here]
Your password is: [insert here]

Public reporting burden of this collection of information is estimated to average 35 minutes
per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data 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 Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333,
ATTN: PRA (0920-0969)

CS292372-A

I. Health Center Characteristics
1.

What best describes your health center’s clinical focus? (Select one.)
Family planning/reproductive health

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Primary (general health) care
Public health (e.g. county health department)
Other:_________________________
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Which best describes the area that your health center serves? (Select one.)
Mostly urban/suburban

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Mostly rural
Combination of rural & urban/suburban
3.

Approximately how many clients received any clinical services at your health center in the last year? (Fiscal or calendar) (Select one.)
<500

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500–999
1,000–4,999
5,000–9,999
10,000–49,999
50,000 +
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Approximately how many clients received family planning services at your health center in the last year? (Fiscal or calendar) (Select one.)
<500

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500–999
1,000–4,999
5,000–9,999
10,000 +
5.

Is your health center a part of the following health care networks?
(In each row, select one.)

Accountable care organization
Medical home (PCMH or other)
Medicaid managed care
Other managed care network/PPO
Participating provider in one or more types of private insurance
6.

Yes

No

Don’t know

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What is the approximate age and gender breakdown of your health center’s family planning clients?
Among female clients
Percentage less than 20 years old

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Percentage 35 years or older

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Among male clients
Percentage less than 20 years old

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Percentage 35 years or older

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Percentage of clients (all ages) that are male

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II. Clinical Services Provided
7.

In the past three months, were the following contraceptive methods* provided on-site to clients who requested them?
Provided on site in last 3 months
Sterilization (male)
Sterilization (female)
LNG-IUD (Mirena,® Liletta,® Skyla,® Kyleena®)
Cu-IUD (ParaGard®)
Implant (Nexplanon®)
DMPA (Depo-Provera®)
Patch (Ortho Evra,® Xulane®)
Vaginal ring (NuvaRing®)
Combined Oral Contraceptives (COCs)
Progestin-only oral contraceptives
Emergency contraceptive pills
Male condom
Female condom
Instruction on fertility awareness-based methods

Yes

No

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* Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

8.

In the past 3 months, about how often did your health center provide the following services?
Never

Rarely

Occasionally

Frequently

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Pregnancy diagnosis & counseling
Contraceptive services for women
Contraceptive services for men
Counseling on how to achieve pregnancy for women
Counseling on how to achieve pregnancy for men
Basic infertility services for women
Basic infertility services for men
STD screening for women
STD screening for men
Preconception health care for women
Preconception health care for men
Assess pregnancy intention/reproductive life plan for women
Assess pregnancy intention/reproductive life plan for men

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9.

The following questions refer to your health center’s clinical recommendations for basic infertility services provided on-site during initial or
follow-up family planning visits.
Is this specified in a written
protocol for female clients?

Is this specified in a written
protocol for male clients?

Yes

No

Yes

No

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Assessment of:
Past surgery, illnesses, injury, infection (including STDs)
Fertility history
Current medication use and allergies
How long client has been trying to achieve pregnancy
Intercourse frequency and timing
Physical examination for infertility-related morbidity
Pelvic examination
Sexual health assessment

10. The following questions refer to your health center’s provision of on-site, routine screening during initial or follow-up family planning visits.
By screening, we mean the process of routinely asking questions about a client’s history or performing a physical exam or laboratory test in
average-risk asymptomatic persons to help assess risk factors for, or the presence of, a specific disease or condition.
Is this service offered
for female clients?
Intimate partner violence
Alcohol use
Drug use
Tobacco use
Depression
Immunizations
Body-mass index (BMI)
High blood pressure
Diabetes
Chlamydia
Gonorrhea
Syphilis
HIV
Hepatitis C
Breast cancer
Cervical cancer
Folic acid intake

Is this specified in a written
protocol for female clients?

Is this service offered
for male clients?

Is this specified in a written
protocol for male clients?

Yes

No

Yes

No

Yes

No

Yes

No

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Testicular cancer

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11. The following questions relate to your health center’s clinical recommendations for contraceptive counseling.
Is this specified in a written protocol
for female clients?

Is this specified in a written protocol
for male clients?

Yes

No

Yes

No

Use open-ended questions

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Assess the client’s reproductive life plan (i.e., ask about their
intentions regarding the number and timing of pregnancies in
the context of their personal values and life goals)

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Elicit client’s preferences regarding contraception

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Present information regarding potential contraceptive
methods based on the patient’s preferences regarding
contraception

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Present information regarding potential contraceptive
methods with the most effective methods presented first
(tiered approach)

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Help client consider other factors they need to know about
contraceptive methods, such as possible side effects

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Help the client think about potential barriers to using their
selected method correctly and develop a plan to deal with
these barriers

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Inform clients about the full range of contraceptive
choices

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Counsel on how to obtain emergency contraception
Counsel on condom use to prevent STDs
Inform clients about fertility awareness-based methods as a
contraceptive option

III. Health Center Infrastructure and Communication Systems
12. In the past 3 months, about how often did your health center make available the following services or materials to clients?
Same-day appointments for clinical services
Weekend or evening hours for clinical services
Adolescent-only hours or days for clinical services
Educational materials (written or video) specifically designed for adolescents
Educational materials (written or video) in languages that match the needs of your client base
Language translation services that match the needs of your client base

Never

Rarely

Occasionally

Frequently

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13. In the past 3 months, about how often did your health center do the following, related to adolescent clients?
Never

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Actively encouraged communication between adolescents and parents/guardians about sex
and reproductive health

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Actively promoted the availability of confidential services to adolescents

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Provided information clarifying that avoiding sex is an effective way to prevent pregnancy
and STDs

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Offered time alone with a provider for adolescents who come with a parent or guardian
Required parental consent, for adolescents seeking contraceptive services

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14. An Electronic Health Record (EHR) is a digital version of a patient’s paper chart and contains information about a patient’s medical history,
diagnoses, immunization dates, allergies, test results, and more.
Yes

No

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Does your health center currently use an EHR system?
If yes, please specify the EHR vendor name: ____________________________________________

15. If your health center uses an EHR, is there a place within your EHR interface (not in a Notes section) to capture the following patient
information?
Patient pregnancy intention
If yes, do you use One Key

Question®?

Sexual history
Ever had sex
Currently sexually active
Contraceptive method provided at end of visit

Yes

No

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16. In the past 12 months, did your health center use any of the following methods for community education? 
Websites
Social media (e.g., Facebook, Twitter)
Other (specify): ____________________________
17. In the past 12 months, did your health center conduct community education in the following places or groups?
Yes

No

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No

Yes: Limited use

Yes: Routinely

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Schools
Colleges or universities
Other youth-serving groups
Parent groups
Faith-based organizations
Other (specify): ___________________
18. Does your health center communicate with clients in the following ways: (In each row, select one)
Text message
Email
Phone calls
Online platform to schedule appointments
Online platform to view lab test results

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IV. Referral Arrangements and Staff Training
19. What kinds of partnerships does your health center have with providers who offer the following contraceptive methods and other services?
(In each row, select all that apply.)

For non-contractual relationships only:
We offer
this
on site

Co-located with those
who do, or our parent
organization provides this

Contract, or
other written
agreement

Active referral*

Passive referral**

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Contraception methods
Female sterilization
Male sterilization
IUD insertion
IUD removal
Implant insertion
Implant removal
Instruction on natural family planning
(fertility awareness-based methods)
Primary care services
Prenatal care services
Adoption services
Treatment services
HIV treatment
Diabetes care
High blood pressure care
Tobacco cessation
Alcohol abuse treatment
Substance abuse treatment
Weight management for obesity
Treatment for depression
Infertility services
Basic infertility services
Semen analysis
Infertility treatment by a specialist

* Active referral includes making an appointment for client, contacting the client directly about the referral outcome, or contacting the referral source to find out if the
client was seen.
**Passive referral includes providing a resource listing or directory to the client, or providing a documented referral to the client.

20. Please indicate whether all, some, or none of the health center’s staff have received training in the following areas:
All staff

Some staff

No staff

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Trained in past 2 years: All relevant staff
Contraceptive counseling
Counseling on fertility awareness-based methods
Client-centered counseling
Overview of all current contraceptive methods (e.g., safety, side effects, benefits, how to use)
Serving male clients
Ever trained: Clinical staff only
Inserting and removing copper IUD
Inserting and removing hormonal IUD
Inserting and removing contraceptive implants

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V. Questions about Survey Completion and Awareness of Guidelines
21. Which of the following best describes the primary role of the person
or persons who completed this survey? (Select all that apply.)
Administrator
Medical director
Nurse/nurse practitioner manager
Other (please specify) _____________________

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22. If your health center is a part of a multi-site agency, did you
consult your parent agency to complete this survey? (Select one.)
Yes, parent completed entire survey
Yes, parent completed or checked parts of the survey
No, parent did not help complete or check the survey
No, we are not part of a multi-site agency
No, we are the parent agency

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24. Have you heard about the 2016 federal guidance entitled,
“Providing Family Planning Care for Non-Pregnant Women and
Men of Reproductive Age in the Context of Zika” (also known as
the “Zika toolkit”)? (Select all that apply)
No, I have not heard about it
Yes, I heard about it, but haven’t read it
Yes, I heard about it, and have read it
Yes, and I use/used it
25. Have you heard about the federal guidance entitled,
“2015 STD Treatment Guidelines”? (Select all that apply)
No, I have not heard about it
Yes, I heard about it, but haven’t read it
Yes, I heard about it, and have read it
Yes, and I use it

23. Have you heard about the 2014 federal guidance entitled,
“Recommendations for Providing Quality Family Planning
Services” (also known as the “QFP”)? (Select all that apply)
No, I have not heard about it
Yes, I heard about it, but haven’t read it
Yes, I heard about it, and have read it
Yes, and I use it

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Please share any additional comments that you may have in the space below.

Thank you for completing this survey!

Please return using the enclosed business reply mail envelope.
Page 8 of 8

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