To provide the best care possible, your school-based health center needs your honest opinion about the care you receive there. DO NOT write your name on the survey; it is confidential. Just tell us what you think!!

Print out and check, circle or fill-in your answers where appropriate.

Female Male Age
Grade: 6th 7th 8th 9th 10th 11th 12th
How often have you used the health center this school year?
First time 2-5 times 6-10 times More than 10 times
What are you being seen for today? (OPTIONAL)

Who are you seeing today?(Check one)

Health Assistant/Receptionist Nurse Counselor
Nurse Practitioner/Physician’s Doctor Other

Did you have an appointment or did you walk-in for care today?

Appointment Walk-in

Is it easy to get an appointment at the school health center?

Always Usually No

Is the location convenient for you?
Yes No

Are the hours convenient for you?
Yes No

Do you feel comfortable talking with the staff about your problems?
Yes No

Do you usually understand the information and advice that the staff give you about medical concerns/problems?
Yes No

How likely are you to follow the advice of health center staff?

Very likely Likely Maybe Probably not

Do you feel your questions are adequately answered?
Yes No

Sometimes Do you feel that your visits are private?
Yes No

Is the clinic comfortable and well-decorated?
Yes No

What do you think about the size of the clinic space?
Too small (need more space) Just right Too big (need less space)

How do you rate the medical care you receive at your school health center?

Excellent Good Okay Poor

If your school health center offers counseling, how do you rate these services?

Excellent Good Okay Poor Never Used

Overall, how would you rate the health center at your school?

Excellent Good Okay Poor

If your school did not have a health center, would you have to miss some school to take care of your concern today?

Yes No Maybe

If your school did not have a health center, would you have gone somewhere else to take care of your concern today?

Yes No Maybe

If yes, where would you have gone? ______________________________

(Examples-regular doctor, county health clinic, family planning clinic, emergency room)

What do you like most about your school health center?________________________________ _____________________________________

What would you change about your school health center and/or what services would you like that are not there already?_____________________________ ____________________________________________________

Thanks for filling out this survey!!! Your answers are important and will be kept private. Surveys will be sent to the Oregon Health Division (state health division) for data collection; they will not be read by health center staff.