Yavapai Pride In Our Health Partner Application
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1.
Practice Name:
(Required.)
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2.
Address(es)
(Required.)
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3.
What is your practice specialty/subspecialty?
(Required.)
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4.
Facility training representative or administrator name:
(Required.)
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5.
Facility representative or administrator phone number:
(Required.)
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6.
Facility training representative or administrator email address:
(Required.)
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7.
Approximately how many clinical staff does your practice employ?
(Required.)
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8.
Approximately how many non-clinical staff does your office employ?
(Required.)
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9.
Do you offer training specific to LGBTQ+ competent healthcare to both your non-clinical and clinical staff?
If you already do this, you are halfway there to being a Pride in Our Health Provider!
If you need support in finding trainings, please select “no, but we are interested and would like more information”. When you complete this survey, you will be provided with a list of training resources that apply.
(Required.)
Yes
No, but we are interested in this kind of training and would like more information.
No, we are not interested in taking this kind of training
If yes, please provide some information about through whom your staff received this training
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10.
Does your facility have a patient nondiscrimination policy that includes language around sexual orientation and gender identity?
If you have this, you're halfway there to becoming a Pride in Our Health Provider!
If you need support in putting together this document, please select “no, but we are interested and would like more information” and someone will contact you with support on creating a policy.
(Required.)
Yes
No
No, but we are interested and would like more information
11.
If you responded yes to the last question, please indicate how this policy is communicated to patients. Otherwise, please skip.
Posted on facility website
Posted or displayed in waiting rooms and other public areas of the facility
In materials routinely given to patients at admitting/registration
In materials routinely given to patients at other time(s)
In materials routinely available for take-away in patient waiting areas
Posted in patient waiting area(s)
12.
Does your facility have an equal visitation policy?
Yes (please upload and send a copy of this policy to PrideInOurHealth@yavapaiaz.gov)
No
No, but we are currently writing this
No, but we are interested and would like more information
Not applicable.
13.
Please select what information your intake forms collect. If your intake forms collect any of the below information, please upload and send a copy to PrideInOurHealth@yavapaiaz.gov
Sexual Orientation
Gender Identity
Gender Assigned At Birth
Pronouns
Preferred Name
Legal Name
None of the above, but we are revising our intake forms to include this information
None of the above, but we are interested in making this change and would like more information.
None of the above
14.
If yes, are you using the above information for patient care, insurance purposes, and/or billing?
Yes
No
N/A
15.
Do your intake forms offer nongendered questions around OBGYN information?
For example, instead of only asking female patients to answer when their last menstruation was, ask all patients and give them the option to choose "not applicable".
Yes (please upload and send a copy of your intake form to PrideInOurHealth@yavapaiaz.gov)
No
No, but we are revising our intake forms to include this information
No, but we are interested in making this change and would like more information.
16.
Do your intake forms offer questions around family/spouse relationships that are inclusive of all types of families?
For example, instead of only giving a patient the option to state "single, widowed, married, separated, and divorced", you can also give them the option to select that they are "cohabitating with a partner".
Yes (please upload and send a copy of your intake form to PrideInOurHealth@yavapaiaz.gov)
No
No, but we are revising our intake forms to include this information
No, but we are interested in making this change and would like more information.
17.
Optional: Do any of your clinicians self-identify as a member of the LGBTQ+ community?
Yes, and they are comfortable with that information being made public on the YPOH webpage by stating “Facility has a clinician that self-identifies as a member of the LGBTQ+ community”. (Clinician's name will not be identified.)
Yes, but they want that information to remain private.
No, but they are committed to providing competent care to LGBTQ+ individuals as an ally.
Choose not to disclose.
18.
For inpatient facilities, and publicly funded and/or nonprofit practices only, do you participate in the Human Rights Campaigns Health Equality Index?
Yes, we are listed in the HEI directory.
Yes, we have submitted our application to participate.
No.
No, but we are interested in receiving more information.
Not applicable.
