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Family Planning Community Needs Assessment
Your feedback will help us improve family planning and reproductive health services in our community. This survey is anonymous and voluntary. Your responses will be used to better understand community needs and improve access to quality healthcare.
Section 1: About You
1.
What county do you live in?
Adams
Pike
Schuyler
2.
What is your age?
Under 15
15-17
18-24
25-34
35-44
45-54
55+
3.
What best describes your gender identity?
Female
Male
Non-gender
Prefer to self-describe
Prefer not to answer
4.
What best identifies your race/ethnicity?
American Indian/Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian/Pacific Islander
White
Other
Prefer not to answer
5.
Which best describes your household income?
less than $32,000
$32,000-$64,000
$64,001-$96,001
Over $96,001
Unsure
Prefer not to answer
6.
Do you currently have health insurance?
Private Insurance
Medicaid
Medicare
No Insurance
Other
Section 2: Healthcare Access
7.
Do you have a regular healthcare provider that you see routinely?
Yes
No
8.
Have you delayed or avoided healthcare in the past 12 months?
Yes
No
9.
If you answered yes in question 8, what were the reasons?
(Check all that apply.)
Cost
No insurance
Transportation
Childcare
Couldn't get an appointment
Clinic hours
Didn't know where to go
Privacy concerns
Language barriers
Fear of being judged
Other
Section 3: Family Planning Services
10.
Have you ever used family planning services?
Yes
No
11.
If you answered yes in question 10, what services have you used?
(Check all that apply.)
Birth control
Pregnancy testing
STI testing
STI treatment
Annual exams
Cervical cancer screening
Breast exams
Emergency contraception
Preconception counseling
Infertility services
HIV testing
PrEP (pre-exposure prophylaxis for HIV)
Men's reproductive health
Other
Section 4: Needed Services
12.
Which services would you like easier access to?
(Check all that apply.)
Birth control
STI testing
HIV testing
Pregnancy testing
Prenatal referrals
Preconception counseling
Infertility services
Cancer screenings
Men's services
Adolecent services
LGBTQ+ services
Sexual health services
Mental health referrals
Substance use referrals
Domestic violence resources
Other
Section 5: Barriers
13.
What makes it difficult to receive reproductive healthcare?
(Check all that apply.)
Cost
Transportation
Work schedule
Childcare
Clinic location
Limited clinic hours
Lack of insurance
Language
Privacy concerns
Fear of others finding out
Cultural concerns
Don't know what services are available
Other
Section 6: Preferred Access
14.
Which clinic hours would work best for you?
Morning
Afternoon
Evening
15.
How would you prefer to schedule appointments?
Phone
Online
Text
Walk-in
16.
How would you like to receive health information?
(Check all that apply.)
Facebook
Instagram
Website
Email
Text message
Printed brochures
School
Healthcare provider
Community events
Section 7: Community Awareness
17.
Before today, were you aware that low-cost or free family planning services were available locally?
Yes
No
18.
How did you hear about these services?
Friend/family
Healthcare provider
School
Social media
Health department
Community organization
Internet search
Other
Section 8: Satisfaction (If previously used services)
19.
If you've used our services, please rate the following:
Excellent
Good
Fair
Poor
Ease of scheduling
Excellent
Good
Fair
Poor
Wait time
Excellent
Good
Fair
Poor
Staff respect
Excellent
Good
Fair
Poor
Privacy
Excellent
Good
Fair
Poor
Provider communication
Excellent
Good
Fair
Poor
Section 9: Community Priorities
20.
What are the three biggest reproductive health concerns in your community?
(Check up to three.)
Unintended pregnancy
Teen pregnancy
STIs
HIV
Access to birth control
Cost of care
Infertility
Lack of education
Access for adolecents
Domestic violence
Mental health
Substance use
Transportation
Section 10: Final Thoughts
21.
What additional services would you like to see offered?
22.
What is one thing healthcare providers could do to better meet the needs of people in your community?