Client Survey School Health Centers /

The following survey asks about your experiences with the [insert school health center name]. Please check one answer for each question, unless the instructions say to check more than one. You don’t have to answer any questions that you do not want to answer. Thank you for taking the time to complete this survey!

First, please tell us about yourself.

  1. What is your gender?

Male

Female

Or ______

  1. What is your grade?

6th
7th
8th
9th / 10th
11th
12th
Other: ______
  1. What is your ethnicity?

African American
Asian
Filipino
Latino / Pacific Islander
White
Biracial/Multiracial
Other: ______
  1. What kind of health insurance do you have?

Kaiser
Medi-Cal / Private (Health Net, Blue Cross, Aetna) / I don’t have insurance
Not Sure
  1. Where do you USUALLY go for health care (to get help from a doctor or nurse)?You can check MORE THAN ONE BOX for this question.

The health center or clinic at my school
Kaiser (not at my school)
Hospital or emergency room
Private doctor
Community clinic (______) / Some other place
I don’t have anywhere to go
I don’t know
  1. If you did not have the School Health Center at your school, what would you have done about your health problem/need today?

Gone to another doctor or nurse
Talked to my friends / Nothing
Other: ______
Doesn’t apply
  1. Which services have you received from the School Health Center this school year? (Check all that apply)

Medical care, such as a physical/wellness exam or check-up

Counseling or talking to someone about issues like stress, feeling sad, or family problems

Counseling or talking to someone about alcohol or drug use

Information on or help with sexual health issues, like birth control/condoms or testing for pregnancy/STDs

Information on or help with diet, nutrition, or exercise

Help with planning academic/behavioral goals, getting information/resources, or other personal support

Other services: ______

Does not apply – I have never used the School Health Center

  1. Which group program or programs did you participate in through your School Health Center this school year? (Check all that apply)

[Insert names of SHC’s group programs, options tailored for each SHC]

Does not apply – I don’t participate in any of these programs

  1. How many times during this school year have you gone to the School Health Center to get services or to participate in group programs?

None

1 or 2 times

3 to 5 times

6 to 9 times

10 times or more

  1. How many years have you been coming to the School Health Center to get services or participate in group programs?

This is my first year

2 years

3 years

4 years

For the next series of questions, please tell us about your experiences with the School Health Center services or programs overall.

When I went to the Health Center for
services or programs… / Strongly Agree / Agree / Disagree / Strongly Disagree / Don’t Know/ Does Not Apply
I was welcomed and greeted warmly.
The people who work there helped me to work through my problem.
The people who work there were easy to talk to.
It was easy to see someone when I needed to.
It felt like a safe place.
I liked having it at my school.
I would recommend it to my friends.
They helped me to get services I wouldn’t otherwise get.
They helped me get help sooner than I normally would.
They helped me get the information and resources that I needed.

For the next series of questions, please tell us whether the School Health Center services or programs affected your health behaviors.

The Health Center services or
programs helped me to… / Strongly Agree / Agree / Disagree / Strongly Disagree / Don’t Know/ Does Not Apply
Feel safe talking about my problems.
Feel more confident.
Feel like I had an adult I could turn to if I needed help or support.
Deal with my stress or anxiety better.
Avoid getting into fights.
Treat people better (for example, less name-calling
or teasing).
Deal with personal or family issues.
Eat healthier foods.
Exercise more.
Stop using or use less tobacco, alcohol, or drugs.
Use protection (condoms or birth control) more often when I have sex.

For the next series of questions, please tell us whether the School Health Center services or programs affected your school experience or plans for the future.

The Health Center services or programs helped me to… / Strongly Agree / Agree / Disagree / Strongly Disagree / Don’t Know/ Does Not Apply
Do better in school.
Have better attendance (cut classes less).
Stay in school.
Get involved in leadership programs.
Have goals and plans for the future.
Feel more connected to people at my school.

Please answer the next series of questions only if you were part of a group program at the School Health Center.

The Health Center services or programs helped me to… / Strongly Agree / Agree / Disagree / Strongly Disagree / Don’t Know/ Does Not Apply
Feel more like a leader.
Feel like I can teach others.
Make my school a better place.
Learn skills that will help me in my future.
Have a stronger college application.

Some final questions for everyone…

  1. Overall, how satisfied are you with your School Health Center?

Very satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

  1. Are there any other ways that the School Health Center services or programs have helped you?
  1. Do you have any ideas about how to make the School Health Center services or programs better?
  1. Are there other services or programs you would like to see at your School Health Center that are
    not offered now?

Produced byThe Center of Healthy Schools and Communities | School Health Works1