TGNB TransFORCE patient survey Question Title * 1. What is your gender identity? Transgender Male/transmale Transgender Female/transfemale Male Female Genderqueer/Non Binary/Gender Expansive/Gender Non Conforming/Gender Variant Stealth/Low Disclosing Something else not listed here OK Question Title * 2. What is your age? Under 18 18-24 25-34 35-44 45-54 55-64 65+ OK Question Title * 3. What is your race? White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native South Asian/Indian Native Hawaiian or other Pacific Islander Arab Middle Eastern/North African Multiracial OK Question Title * 4. What is your sexual orientation? Gay Straight Lesbian Bisexual Queer Pansexual Asexual Something else not listed here OK Question Title * 5. What is your income level? No income Under $15,000 Between $15,000 and $50,000 Between $50,000 and $100,000 Over $100,000 Prefer not to answer OK Question Title * 6. What is your housing status? Stably Housed (paying rent to a landlord, living with family) Unstably housed (doubling up, couch surfing) Homeless (squatting, sleeping on train/park/car, at a shelter) OK Question Title * 7. What is your current employment status? Full time employee Part Time employee Freelance/"off the books" (dog walking, child care, sex work) Unemployed Something not listed here OK Question Title * 8. What is your health insurance status? Private Insurance (insurance through school, parents, employer, union) Affordable Care Act Plan (Obamacare, plan purchased on marketplace exchange) Public (Medicaid, Medicare, CHP, ADAP) Uninsured (I currently have no health insurance) I don't know OK Question Title * 9. What are some of your barriers to health care (check all that apply)? I have not experienced barriers Transportation Housing Issues No one to go with me Personal mental health issues Lack of disclosure/not wanting people to know I go to Callen-Lorde Location/travel time Ability/mobility/chronic illness Lack of transgender competent care Migrant/Immigration Status No/low income No insurance Discrimination at the clinic Police Interaction/Incarceration Appointment Availability Personal safety in public Other (please specify) OK Question Title * 10. Please rate the care you have received from the following areas with 1 being the worst and 5 being the best 1 2 3 4 5 N/A Front Desk/Patient Care Associates Front Desk/Patient Care Associates 1 Front Desk/Patient Care Associates 2 Front Desk/Patient Care Associates 3 Front Desk/Patient Care Associates 4 Front Desk/Patient Care Associates 5 Front Desk/Patient Care Associates N/A Nursing Nursing 1 Nursing 2 Nursing 3 Nursing 4 Nursing 5 Nursing N/A Medical Providers Medical Providers 1 Medical Providers 2 Medical Providers 3 Medical Providers 4 Medical Providers 5 Medical Providers N/A Mental Health Providers Mental Health Providers 1 Mental Health Providers 2 Mental Health Providers 3 Mental Health Providers 4 Mental Health Providers 5 Mental Health Providers N/A Insurance Navigation Insurance Navigation 1 Insurance Navigation 2 Insurance Navigation 3 Insurance Navigation 4 Insurance Navigation 5 Insurance Navigation N/A Case Managment Case Managment 1 Case Managment 2 Case Managment 3 Case Managment 4 Case Managment 5 Case Managment N/A Dental Dental 1 Dental 2 Dental 3 Dental 4 Dental 5 Dental N/A Pharmacy Pharmacy 1 Pharmacy 2 Pharmacy 3 Pharmacy 4 Pharmacy 5 Pharmacy N/A Security Security 1 Security 2 Security 3 Security 4 Security 5 Security N/A HOTT HOTT 1 HOTT 2 HOTT 3 HOTT 4 HOTT 5 HOTT N/A OK Question Title * 11. Staff at Callen-Lorde use my correct pronoun Always Usually Sometimes Rarely Never OK Question Title * 12. I feel my medical provider is well versed in transgender care Strongly agree Agree Somewhat agree Neither agree nor disagree Somewhat disagree Disagree Strongly Disagree Please elaborate on why you chose this answer OK Question Title * 13. Have you ever had trouble accessing your hormones at Callen-Lorde? Yes No I do not access hormones at Callen-Lorde Other (please specify) OK Question Title * 14. How important is it to you that your provider (either medical or mental health) is TGNB identified? Extremely important Very important Somewhat important Not so important Not at all important OK Question Title * 15. How important would it be for you for Callen-Lorde to add spirituality/pastoral care services for TGNB patients? Very Important Important I do not feel strongly about this/I don't need this I would prefer you NOT add these services Please elaborate OK Question Title * 16. Would you prefer that Callen-Lorde have a standalone TGNB clinic (a space that is specifically for transgender patients with providers focusing on TGNB care)? Yes No Please explain why you answered this way OK Question Title * 17. Have you accessed TGNB specific surgery coordination (letters, pre/post surgical appointments, surgery education) while a patient of Callen-Lorde? Yes No OK NEXT