Family Planning Program Client Survey

1. Which age range do you fall under? *This question is required.

• 17 years old and under
• 18 years old and over

2. Was your visit today scheduled or a walk-in? *This question is required.

• Scheduled
• Walk-in

3. Did the selection of available appointment times meet your needs? *This question is required.

• Yes
• No

4. Why did you choose our services?
Check all that apply. *This question is required.

• The services are confidential.
• I can get my birth control supplies at this clinic.
• It was easy to get an appointment.
• I like the clinic staff.
• The clinic is close and easy to find.

• This is the only convenient clinic.
• Another healthcare provider referred me here.
• A friend or family member recommended this clinic.
• The clinic has free or low-cost services.
• Other Please enter an 'other' value for this selection. * This question is required.

5. Where do you usually go for general health services (i.e., when you need a check-up, want advice about a health problem, or get sick or hurt)? *This question is required.

• This clinic
• Another clinic
• Emergency Room

• Urgent Care
• Nowhere
• Other Please enter an 'other' value for this selection.

6. Did clinic staff explain that today's visit was confidential? *This question is required.

• Yes
• No

7. Did you receive your family planning method of choice during your visit today? *This question is required.

• Yes
• No
• Not applicable

8. Are you aware that this clinic provides reproductive health services (STI testing) to men? *This question is required.

• Yes
• No

10. Think about your visit. Please indicate how much you agree or disagree with the statements below. *This question is required.

Space Cell	Not Applicable	Strongly disagree	Disagree	Neutral	Agree	Strongly Agree
I was greeted in a friendly, professional manner.	I was greeted in a friendly, professional manner.: Not Applicable	I was greeted in a friendly, professional manner.: Strongly disagree	I was greeted in a friendly, professional manner.: Disagree	I was greeted in a friendly, professional manner.: Neutral	I was greeted in a friendly, professional manner.: Agree	I was greeted in a friendly, professional manner.: Strongly Agree
I was treated in a non-judgmental, respectful way.	I was treated in a non-judgmental, respectful way.: Not Applicable	I was treated in a non-judgmental, respectful way.: Strongly disagree	I was treated in a non-judgmental, respectful way.: Disagree	I was treated in a non-judgmental, respectful way.: Neutral	I was treated in a non-judgmental, respectful way.: Agree	I was treated in a non-judgmental, respectful way.: Strongly Agree
I felt comfortable asking questions to the staff.	I felt comfortable asking questions to the staff.: Not Applicable	I felt comfortable asking questions to the staff.: Strongly disagree	I felt comfortable asking questions to the staff.: Disagree	I felt comfortable asking questions to the staff.: Neutral	I felt comfortable asking questions to the staff.: Agree	I felt comfortable asking questions to the staff.: Strongly Agree
I was given enough information to help me decide on what STI testing was most appropriate.	I was given enough information to help me decide on what STI testing was most appropriate.: Not Applicable	I was given enough information to help me decide on what STI testing was most appropriate.: Strongly disagree	I was given enough information to help me decide on what STI testing was most appropriate.: Disagree	I was given enough information to help me decide on what STI testing was most appropriate.: Neutral	I was given enough information to help me decide on what STI testing was most appropriate.: Agree	I was given enough information to help me decide on what STI testing was most appropriate.: Strongly Agree
My preferences about my birth control were taken openly and seriously.	My preferences about my birth control were taken openly and seriously.: Not Applicable	My preferences about my birth control were taken openly and seriously.: Strongly disagree	My preferences about my birth control were taken openly and seriously.: Disagree	My preferences about my birth control were taken openly and seriously.: Neutral	My preferences about my birth control were taken openly and seriously.: Agree	My preferences about my birth control were taken openly and seriously.: Strongly Agree
I was given enough information to make the best decision about my birth control method.	I was given enough information to make the best decision about my birth control method.: Not Applicable	I was given enough information to make the best decision about my birth control method.: Strongly disagree	I was given enough information to make the best decision about my birth control method.: Disagree	I was given enough information to make the best decision about my birth control method.: Neutral	I was given enough information to make the best decision about my birth control method.: Agree	I was given enough information to make the best decision about my birth control method.: Strongly Agree

11. Overall, how satisfied were you with the services you received at your visit today? *This question is required.

Very Dissatisfied	Dissatisfied	Neutral	Satisfied	Very Satisfied
Very Dissatisfied	Dissatisfied	Neutral	Satisfied	Very Satisfied