Health Care Providers Survey

Hello-

This is a survey to gain a better understanding of relationships in the state of Iowa between health care providers and the LGBTQ community. It should not take longer than five minutes. We appreciate all feedback and look forward to your response.

We will post your answers publicly on our LGBTQ Health Resource List. If we need more information about your responses to this survey, we will reach out using the contact information you provide.

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* 1. Do your intake forms request any of the following information (please check all that apply)

Sexual orientation

Preferred name

Gender identity

Preferred pronouns

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* 2. Does your facility have a written non-discrimination policy?

Yes

I don't know

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* 3. If you answered yes to question 2, does your non-discrimination policy include either of the following?

Gender identity

Sexual orientation

Both

Neither

My facility does not have a written non-discrimination policy

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* 4. Has your facility served members of the LGBTQ community?

Yes

I don't know

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* 5. Has your staff experienced any issues with a client or patient because of their sexual orientation or gender identity?

Yes

I don't know

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* 6. Has your facility designed and implemented protocol to deal with individuals based on sexual orientation or gender identity?

Yes

I don't know

If your facility does have protocol, what is it?

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* 7. Have you and/or any of your staff participated in an LGBTQ-specific cultural competency training?

Yes

I don't know

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* 8. Would you and/or your staff be interested in receiving LGBTQ-specific cultural competency training?

Yes

Maybe

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* 9. Please provide your contact information:

Name

Facility

Address

State

Zip Code

Phone

Website