BFWHW Provider Survey

Bright Futures for Women’s Health and Wellness Initiative
Survey for Individuals Distributing the Bright Futures for Women’s Health and
Wellness: Emotional Wellness Tools
Please answer the following questions by checking the circle or circles next to your answer.
1.

Please indicate your sex:
{ Male
{ Female

2.

Please indicate your age group:
{ 18-24
{ 25-44
{ 45-64
{ 65+

3.

Are you Hispanic or Latina?
{ Yes
{ No

4.

Which of the following would you say is
your race (please select one or more)?
{ White
{ Black
{ American Indian or Alaska Native
{ Asian
{ Native Hawaiian or other Pacific Islander

5.

6.

What is your role in your organization?
{ Health care provider
{ Counselor
{ Social worker
{ Outreach worker
{ Peer educator/Promotora
{ Other________________________
What is your primary professional
qualification?
{ Medical Doctor
{ Licensed nurse
{ Licensed social worker
{ Midwife
{ Psychologist
{ Licensed Professional Counselor
{ Advanced Practice Nurse
{ Other ________________________

7.

How many years of experience do you
have in your current profession?
{ Less than 3 years
{ 3 – 5 years
{ 6 – 10 years
{ 11– 20 years
{ More than 20 years

8.

What types of services do you (personally)
provide to the women you see (check all
that apply)?
{ Prenatal care
{ HIV/AIDS treatment
{ Routine medical care
{ Emotional health care
{ Social support or case management services
{ Other_____________________________

9.

Approximately how many individual
women do you (personally) see each
month?
{ 1-10
{ 11-25
{ 26-50
{ More than 50

Please describe the women to whom you
provide services:
10. Approximately what percentage of the
women you (personally) see fall into each
of these age groups?
Under 18 ____%
18-24 ____%
25-44 ____%
45-64 ____%
65+ ____%

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-xxxx. Public
reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

11. Approximately what percentage of the
women you (personally) see are in each of
these race/ethnic groups?
Hispanic ____%
White ____%
Black ____%
Native American or Alaska Native____%
Asian____%
Native Hawaiian or other Pacific
Islander___%
Two or more races ____%
12. How often do the women you (personally)
see talk to you about emotional issues or
emotional concerns?
{ Very often
{ Somewhat often
{ Occasionally
{ Rarely
13. What types of emotional health issues or
concerns are most frequently reported to
you (personally) by the women you see
(check all that apply)?
{ Depression
{ Family or relationship problems
{ Loneliness
{ Substance abuse
{ Anxiety
{ Other ______________________
14. How comfortable are you (personally)
talking about emotional health and wellbeing with the women you see?
{ Very comfortable
{ Mostly comfortable
{ Somewhat comfortable
{ Somewhat uncomfortable
{ Very uncomfortable
15. Were you
(personally) aware
of the Bright
Futures for
Women’s Health
and Wellness
(BFWHW) program
or consumer
Guides prior to this
evaluation?
{ Yes
{ No

16. Did you (personally) distribute any of the
BFWHW Emotional Wellness Guides prior
to this evaluation?
{ Yes (check all that apply)
___ Physical Activity and Healthy Eating
Tools
___ Emotional Wellness Tools
{ No
{ Unsure
17. Approximately how many women have
you (personally) given copies of the
BFWHW Adult Woman’s Guide to
Emotional Wellness since this evaluation
project began?
{0
{ 1-25
{ 26-50
{ 51-100
{ More than 100
18. Approximately how many women ages 13-17
have you (personally) given copies of the
BFWHW Young Woman’s Guide to
Emotional Wellness since this evaluation
began?
{0
{ 1-25
{ 26-50
{ 51-100
{ More than 100
19. To whom and under what circumstances
do you (personally) give the BFWHW
Emotional Wellness Guides?
{ Only to women who express concerns
about emotional wellness
{ Only to women who participate in a
certain program or receive a certain type
of service. Please specify:
____________________________________
____________________________________
{ Most of the women I have seen since the
evaluation began
{ All the women I have seen since the
evaluation began

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-xxxx. Public
reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

20. When you (personally) give women the
BFWHW Emotional Wellness Guides, how
extensively do you usually go through it
with them (e.g., explaining, talking about
it, and/or answering questions)?
{ I spend a minute or two explaining what
it is and why I’m giving it to them
{ I flip through it with them for several
minutes and point out one or two points
of interest
{ I spend 10 or more minutes walking
through the whole Guide with them and
answering questions
{ It varies depending on the circumstance
(e.g., depends on whether the woman
raised any issues of emotional health
herself, how many questions she asks,
what type of appointment)
{ Other ___________________________
21. Do you (personally) think the Woman’s
Guide contains advice that the adult
women you see can use to feel better about
their lives?
{ Yes, it contains very useful advice
{ Yes, it contains some useful advice
{ No, the advice is not very useful
{ Unsure
{ Not applicable (I did not distribute the
Woman’s Guide)
22. Do you (personally) think the Young
Woman’s Guide contains advice that the
young women (under 18) you see can use
to feel better about their lives?
{ Yes, it contains very useful advice
{ Yes, it contains some useful advice
{ No, the advice is not very useful
{ Unsure
{ Not applicable (I did not distribute the
Young Woman’s Guide)

23. How easy do you (personally) find it to
explain and talk about the BFWHW
Emotional Wellness Guides to the women
you see?
{ Very easy to explain and talk about
{ Mostly easy to explain and talk about
{ Neither easy nor difficult to explain and
talk about
{ Somewhat difficult to explain and talk
about
{ Very difficult to explain and talk about
{ I did not distribute the Women’s Guide
24. How relevant do you (personally) think the
examples and personal stories in the
BFWHW Emotional Wellness Guides are
to the lives of the women you serve?
{ Very relevant
{ Mostly relevant
{ Somewhat relevant
{ Somewhat irrelevant
{ Very irrelevant
25. Since you (personally) have been
distributing the BFWHW Emotional
Wellness Guides, do you discuss
emotional wellness with the women you
serve more often than before?
{ Yes, much more often than before
{ Yes, somewhat more often than before
{ No, somewhat less often than before
{ No, much less often than before
{ About the same
{ Unsure
26. Since you (personally) have been
distributing the BFWHW Emotional
Wellness Guides, have you referred more
women for further mental health services
(on average)?
{ Yes, I have referred many more women
for mental health services on average
than I did before
{ Yes, I have referred a few more women
for mental health services on average
than I did before
{ No, I have referred fewer women for
mental health services on average than I
did before
{ About the same
{ Unsure

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-xxxx. Public
reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

27. Would you (personally) recommend these
BFWHW Emotional Wellness Guides to
other professionals in your field?
{ Yes
{ No
{ Unsure

29. Do you plan to continue distributing these
Guides as part of your routine practice even
after this evaluation period is completed?
{ Yes
{ No
{ Unsure

28. Please mark whether you think the
following statements about the BFWHW
Emotional Wellness Guides are True or
False:
T/F They are easy for the women I see to
read and understand.
T/F They are culturally appropriate for the
women I see.
T/F They help women to feel more
comfortable talking about emotional health
and well-being with me or other health
professionals.
T/F They help me to feel more comfortable
bringing up issues of emotional health and
well-being with the women I see.
T/F They are too long.
T/F They are too short.
T/F I often don’t have enough time to
discuss them with the women I see.

30. What other types of educational materials
or consumer tools would you find most
useful in your practice?
_______________________________________
_______________________________________
_______________________________________
31. Additional Comments:
_______________________________________
_______________________________________
_______________________________________

Thank you for your participation!

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-xxxx. Public
reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.