0917-0036 Adolescent School Health

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Adolescent and School Health (ASHS) Teen Clinic Survey

Gender: Age: ­­­­­___ Grade: ____ School: _____________

Date: ____________ Female : ____________ Male: ____________

Please rate the following statements using numbers 1-5 based on this scale: Circle your answer…

1 2 3 4 5

Strongly Disagree

Disagree

Unsure

Agree

Strongly Agree

1. I would recommend this clinic to my friends. 1 2 3 4 5

2. Usually, my health is good. 1 2 3 4 5

3. I am sure I can take care of my health (T’áá hwó’ají t’éego). 1 2 3 4 5

4. I was greeted well today. 1 2 3 4 5

5. I have a person who I think of as my nurse or doctor. 1 2 3 4 5

6. Today the clinic staff made good use of my time. 1 2 3 4 5

7. My health care team explained things clearly to me. 1 2 3 4 5

8. My health care team asked what I wanted when we planned my care. 1 2 3 4 5

9. I was treated well throughout the visit today. 1 2 3 4 5

10. I am able to get the care I need and want-when I need it and want it. 1 2 3 4 5

11. I felt comfortable discussing private issues with my healthcare team 1 2 3 4 5

What did we do well today? _____________________________________________________________________________________

What can we do better? _____________________________________________________________________________________

Revised: 9/2/14

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The   valid OMB control number for this information collection is 0917-0036.  The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.