Student Survey

We would like to know what you think about the School Health Clinic.  We will use your comments to make the clinic better.  Your answers will not be seen by your provider.  And we will keep anything you tell us private (we will not share with anyone outside of the clinic.)  So, please do not write your name on this.

* 1. Name of School-Based Health Center

* 2. What is your age?

* 3. What is your sex?

* 4. What is your race?

* 5. What is your ethnicity?

* 6. Why did you come into the clinic today?

* 7. Please check one of the following statements:

* 8. At today's visit, did the provider:

  Yes No Not Sure I don't want to answer
a.  Spend enough time with you?
b.  Listen carefully to you?
c.  Explain things in ways you understood?
d.  Make you feel comfortable to ask any type of question?
e.  Ask about your physical health (body changes, weight, etc.)?
f.  Ask about your emotional health (feeling sad, stressed, anxious, etc.)?
g.  Let you know that certain things you talked about are private (not shared with anyone else)?

* 9. What do you think about the clinic after your visit?

  Yes No Not sure I don't want to answer
a.  I'm comfortable talking with the provider about private things (my health, life at home, things that bother me).
b.  I can get information to understand my health.
c.  I know what health services I can get without my parents/guardian knowing or saying OK.
d.  I know how to contact the clinic if I have any questions or problems.
e.  The front desk staff make me feel welcome.
f.  It's easy to get an appointment today.
g.  I don't have to wait too long for an appointment.

* 10. What do you think about the clinic space?

  Yes No Not sure I don't want to answer
The waiting room is comfortable.
It is clean.
It is set up so I can talk with front desk staff without other people hearing me.
The posters and brochures are interesting to me.
Clinic hours are at a time that I can come.

* 11. Were you happy with your visit today?

* 12. Would you come back to the clinic?

* 13. What else would you like to tell us?

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