/ Clinic Senior Survey / A program of the

The School Based Clinic wants to know what YOU think!

You do not have to write your name or any personal information on this survey

  1. Have you ever heard of the school based clinic?
 No Yes, how:
 Teacher  Parent
 Clinic Brochure  Back-to-school Packet
 Friend  Facebook
 Classroom presentation
 Other:______
  1. Have you ever been to the school based clinic?
 No – skip to #4 Yes – go to #3
  1. If you have been to the clinic, what did you like about the services you received? Select all that apply & then skip to #5
The clinic staff were welcoming and easy to talk to
 The waiting area was comfortable and teen friendly
 It’s convenient
 I liked that the services were confidential (private)
 No co-pay/did not need insurance
 Other: ______
  1. If you do NOT visit the clinic, what are some reasons that you do not use the services? Select all that apply
 I visit another clinic or doctor
 Negative past experience with the school based clinic
 Embarrassed to use services
Do not feel welcome in the school based clinic
 Worried my parents will find out
Worried my friends will see me or find out
 I can’t take time out of class
 I don’t know enough about the clinic
 Other: ______
  1. In your opinion, what could we do to bring more students into the clinic? Select all that apply
 Health fairs  Explain privacy practices
Classroom presentations  Changes to waiting area
Special Events  Expanded services
 Peer education  Before/after school hours
 Competitions or promotions  Drop-in appointments
After school groups
 Other: ______/
  1. What health issues do you think the clinic and community should be addressing? Select your top 3
 Mental Health  Teen Pregnancy
 Drug/Alcohol abuse  Sexually Transmitted Infections
 Tobacco use  Relationships /Dating abuse
 Bullying  Communication with parents
 Fitness  How to get health insurance
 Nutrition  How to get confidential health care
 LGBT needs  Youth Violence
 Other: ______
  1. Do you feel thatteachers and school staff are supportive of the School Based Clinic (give you passes or allow you to miss class)?
Yes
No
Not sure ______
  1. Please share any additional thoughts you have about the clinic and its services:
  1. Gender:  Male  Female Transgender
  1. Race:
 American Indian  Asian
White/Hispanic/Latino  Black
  1. Ethnicity:
 Hispanic/Latino  Hmong  Multi-racial
 Non-Hispanic/Latino  Somali  Other African
 Other: ______
/ Version: 04/13 / Page 1 of 1
/ Student Survey / A program of the

Thank you for taking the school based clinic survey!!!

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/ Version: 08/12 / Page 1 of 2