Quality STD Clinical Services Implementation Guide Piloting Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Clinic Name and Location? *

Who is the contact person for follow-up questions and for piloting participation? (Please include a contact email) *

Clinic Type? *

State health department-run

County/City/local jurisdiction health department-run

FQHC

Other

How many staff work in the clinic? *

How many days and hours a week is the clinic open? *

What other services does your clinic provide? *

Who frequents your clinic? What is your patient population? (e.g. age, racial/ethnic makeup, cis/trans, MSM) *

What are your jurisdiction's STI rates? (please include gonorrhea, chlamydia, and syphilis rates) *

Does your clinic have prior experience conducting clinic services or quality improvement assessments? *

Yes

Not sure

Is your clinic accredited? *

Yes

Does your clinic receive Title X funding? *

Yes

Not Sure

We receive other family planning funding.

Does your clinic receive Ryan White funding? *

Yes

Not sure

We receive other HIV prevention or care funding.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy