CCOE Site Visit

(For Office Use Only: CCOE location: ______)

NATIONAL COMMUNITY CENTERS OF EXCELLENCE

(CCOE) IN WOMEN’S HEALTH

NATIONAL EVALUATION: ROUND II

CCOE Client Survey

You were randomly selected to participate in Round II of the National Evaluation of the National Community Centers of Excellence (CCOE) in Women’s Health program. The CCOE program is sponsored by the Department of Health and Human Services (DHHS) Office on Women’s Health (OWH). The goal of the CCOE program is to help coordinate quality health care services and information for women. The survey includes questions about your experience with the <insert CCOE Name>. Please answer the questions to the best of your ability. Choose ‘Does Not Apply’ to a question if you have not received the service. (If you are not sure what the CCOE is or does, please ask someone for help.)

The information you provide will be anonymous. Your name will not be associated with this survey or your responses. If you have any questions or concerns about this survey or would like more information about this project please contact Fatima Riaz at (240) 314-5675 or at 1101 Wootton Parkway, Suite 9246, Rockville, MD 20852.

The survey will only take 10-15 minutes. Thank you for your participation!

______________________________________________________________

1. How did you hear about the CCOE program?

• Friends or family member

• Newspaper/radio

• Television

• Church

• Community Center

• Other, please list: _________________________________

2. Have you received services from this organization before today?

• Yes (go to Question 3)

• No (skip to Question 5)

3. If yes, how long ago was your last visit?

• 3 years ago

• 2 years ago

• 1 year ago

• 6 months ago

• 3 months ago

• 1 month ago

• 3 weeks ago

• Less than 3 weeks ago

4. How long have you been receiving health care from the CCOE?

• Less than one year

• 1-2 years

• 3-5 years

• More than 5 years

Please circle the choice that best reflects your opinion about the CCOE program.

Are you able to easily get to (i.e., access) the CCOE?	Yes	To Some Extent	No
Are you able to speak to someone in your native or primary language?	Yes	To Some Extent	No
Are you treated with respect?	Yes	To Some Extent	No
Is the CCOE staff courteous?	Yes	To Some Extent	No
Do you trust the health professionals at the CCOE?	Yes	To Some Extent	No
Do you usually go to the CCOE when you need health care or health care information?	Yes	To Some Extent	No
Do you have a regular provider (or health care professional) you see at the CCOE?	Yes	To Some Extent	No
Has the CCOE helped you learn how to manage your own health?	Yes	To Some Extent	No	Not Sure
Would you recommend the CCOE to your (female) friends and family?	Yes		No	Not Sure

The CCOE has many programs and services. Please select all of the services or help you received through the CCOE network in the last six months.

Health care services (includes primary and specialty care services)	Transportation assistance (i.e., help in getting to the CCOE)
Referral services (for health care)	Child care services
Counseling services (such as hormone replacement therapy, smoking, diet or weight management, domestic violence, mental health, etc.)	Classes (such as childbirth, exercise, parenting skills programs, or diet)
Printed health information (such as brochures, newsletter, etc.)	Health information hotline/telephone line
Access to the women’s health resource center	Participation in a research study
Clinical resource directory	Internet access
Support groups (such as for substance abuse, domestic violence, alcoholism, working mothers, etc.)	Leadership and skills training
Family Planning Services (such as contraception, safe sex, teen pregnancy, parenting education, or other services)	Mentoring programs
Services for the Elderly (for topics such as osteoporosis, menopause, estrogen replacement therapy, living wills, etc.)	Assistance with getting your medication (such as helping you enroll in Medicare Part D, medication therapy management, etc.)
Other (please list): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section 1: Health Care Service(s)

SKIP to Section 2 if you have NOT received health care services from the CCOE.

What was the main reason for your health care visit to the CCOE? Prenatal or postpartum Contraception (including emergency contraception) STD Routine exam New health problem Follow-up care Other, please specify: ______________________________
Does the CCOE provide you the chance to get both gynecological and general health care?	Yes	To Some Extent	No	Does Not Apply
Were you satisfied with the health professional who provided your care?	Yes	To Some Extent	No	Does Not Apply
Were you satisfied with the overall quality of care you received?	Yes	To Some Extent	No	Does Not Apply
Were you satisfied with the overall coordination of your care?	Yes	To Some Extent	No	Does Not Apply
Did you have to provide the same information (e.g., name, address, phone) more than once?	Yes	To Some Extent	No	Does Not Apply
Did you receive help with scheduling your next visit?	Yes	To Some Extent	No	Does Not Apply
Was it easy to get a referral for a health care service?	Yes	To Some Extent	No	Does Not Apply
If you received a referral, how many business days did it take to get the referral? O 1 day O 2 days O 3 days O 4 days O 5 days O More than 5 days
Did you use the referral?	Yes	To Some Extent	No	Does Not Apply
If you did not use the referral, why not? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section 2: Community Research

SKIP to Section 3 if you have NOT participated in a research study through the CCOE program.

Have you participated in a CCOE research study during the last 6 months?	Yes		No
Was the purpose of the research study explained to you?	Yes	To Some Extent	No	Does Not Apply
Were the procedures of the research study explained to you in an understandable manner?	Yes	To Some Extent	No	Does Not Apply
Was it convenient to participate in the research study?	Yes	To Some Extent	No	Does Not Apply

Section 3: Training

SKIP to Section 4 if you have NOT participated in leadership training or health care skills training sponsored by the CCOE.

Have you been involved in any leadership development and/or skills training (i.e., mentoring) within the last 6 months at the CCOE?	Yes		No
If you received training, list what type of training you took and what you learned. ________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________
Was it easy to sign up for the leadership and skills training?	Yes	To Some Extent	No	Does Not Apply
Did you get a job in health care after you finished the leadership development and/or skills training?	Yes	To Some Extent	No	Does Not Apply
Do you have a mentor who provides you with career advice?	Yes	To Some Extent	No	Does Not Apply
Are leadership opportunities available to you through the CCOE program?	Yes	To Some Extent	No	Does Not Apply
Were you satisfied with the leadership development and/or skills training you received?	Yes	To Some Extent	No	Does Not Apply

Section 4: Classes, Events, and Information

SKIP to the next page if you have NOT taken a class (e.g., breast feeding), attended a community event (e.g., health fair) , or received brochures or other information from the CCOE.

Have you participated in a CCOE sponsored event or class (i.e., health fair or parenting skills classes) during the last 6 months?	Yes		No
If you took a class or attended a health care event, describe the event or class and how you heard about it.
Were you asked for suggestions about topics for educational sessions or classes?	Yes	To Some Extent	No	Does Not Apply
Was the most recent event or class presented in your primary language?	Yes	To Some Extent	No	Does Not Apply
Was the most recent event or class presented in a manner that was respectful of different cultures?	Yes	To Some Extent	No	Does Not Apply
Did you learn new information during your most recent event or class?	Yes	To Some Extent	No	Does Not Apply
Did you change your habits or behavior (e.g., quit or reduce smoking) because of information you learned from an event, class, or information you received?	Yes	To Some Extent	No	Does Not Apply
Did you receive help with finding information resources in women’s health?	Yes	To Some Extent	No	Does Not Apply
Was the information you received helpful?	Yes	To Some Extent	No	Does Not Apply
Was the information you received easy to read?	Yes	To Some Extent	No	Does Not Apply
Was information about healthy living (such as diet and exercise) available to you?	Yes	To Some Extent	No	Does Not Apply

What types of events or classes would you like to see offered by the CCOE?

General Information
How many times did you go to the CCOE (or a CCOE partner) in the last year? ___
Overall, how would you rate your health today?
Excellent			Good					Poor		Very Poor
Do you prefer a male or female health professional to treat you?
Male	Female				Either Male or Female
What is your age? years
I am:
Hispanic or Latino				Not Hispanic or Latino
What is your race/national origin? (check all that apply)
American Indian or Alaska Native Black or African American White							Asian Native Hawaiian or Other Pacific Islander
What kind of health care insurance do you currently have?
HMO Medicare Other		PPO Medicaid I do not have health care insurance
If you are insured by Medicaid, are you dual-eligible for the Medicare Part D Prescription Drug Benefit program?
Yes
No
If you are insured by Medicare or dual-eligible for both Medicaid and Medicare, please select all of the areas the CCOE helped you with from the list below? (check all that apply)
Part D Enrollment Selecting a Plan Understanding your benefits Other
What is your highest level of education?
Less than High School Some College						Some High School College Graduate			High School Graduate Graduate School
What is your household yearly income?
$20,000 or less $20,001 to $50,000						$50,001 to $75,000 $75,001 and over

Share Your Thoughts

How could the CCOE improve the coordination of your health care? Please include any additional services you would like the CCOE and/or their partner organizations to offer.

Thank you for taking this survey.

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CCOE Client Survey