2018.2019 ASHP Adolescent Friendly

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.

Question Title

* 1. Name of School-Based Health Center

Albert Cammon

Avoyelles Charter

Avoyelles High

Bogalusa High

Bonnabel High

Breaux Bridge Jr. High

Broadmoor High

Buckeye High

Carencro Middle

Cecilia Junior High

Chalmette High School

Clinton Middle Health Center

Delhi High School

Eleanor McMain High School

Glasgow Middle

Glen Oaks High

Glenmora High

Grant Jr. High

Jena High

J. S. Clark

Jena Jr. High

John Ehret High

Jonesboro-Hodge High School

Lakeview

Lessie Moore Elementary

Linwood Public Charter

Livonia High

Madison High

Madison Middle School

Marthaville Elementary

McDonogh 35

Molo Middle

Morehouse Junior High

Natchitoches Central

New Orleans Math & Science

Northeast Elementary

Northeast High

Northside High

Northwood SBHC

Oakdale Middle

Pineville Jr. High

Pointe Coupee

Provencal Elementary and Junior

Pollock Elementary

Rayville High

Riser Middle School

Riverdale High School

Scotlandville Middle

South Cameron High

St. Helena Arts and Technical

St. Helena College and Career Academy

St. Martinville Primary

Tioga High

Tioga Junior High

Washington-Marion

West Jefferson High

West Monroe High

West St. Mary High

Westdale Middle

Woodlawn High

Question Title

* 2. What is your age?

Question Title

* 3. What is your sex?

female

male

Question Title

* 4. What is your race?

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific islander

White

More than one race

Question Title

* 5. What is your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Question Title

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

Immunizations/Shots

Didn't feel well, sick, something hurt

Talk to Social Worker

Talk to Nurse, Doctor

Something else

Question Title

* 7. Please check one of the following statements:

Today is the first time I ever visited the Health Center.

Today is the first time I visited the Health Center this school year.

I have already visited the Health Center at least one time this school year.

Question Title

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

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

Question Title

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

Question Title

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

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

Question Title

* 11. Were you happy with your visit today?

Yes

Not sure

Don't want to answer

Comment

Question Title

* 12. Would you come back to the clinic?

Yes

Not sure

Don't want to answer

Comment

Question Title

* 1. Name of School-Based Health Center

Question Title

* 2. What is your age?

Question Title

* 3. What is your sex?

Question Title

* 4. What is your race?

Question Title

* 5. What is your ethnicity?

Question Title

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

Question Title

* 7. Please check one of the following statements:

Question Title

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

Question Title

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

Question Title

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

Question Title

* 11. Were you happy with your visit today?

Question Title

* 12. Would you come back to the clinic?

Question Title

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