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Anonymous Survey for Health Care Provider Trainings
Hi there! **PLEASE READ THIS BEFORE TAKING THE SURVEY** Please take this survey if you are a QUEER PERSON OF COLOR. allgo will be conducting health care provider (HCP) trainings so that HCPs can better serve their QUEER PEOPLE OF COLOR (QPOC) patients. Thank you to all the folks who gave us their invaluable input when we first put together training materials. We want to continue listening to the community so we know which needs to address in the trainings. The survey asks personal information related to identity so that we understand whose needs are remaining unmet. This survey is anonymous and no personally identifying data such as name or email address is collected. Some responses and data from this survey will be used for educational purposes. Thank you so much!
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* Indicates required question
What is your sexual orientation?
*
Queer
Lesbian
Bisexual
Gay
Asexual
Other:
Required
What is your gender?
*
Male
Female
Non-binary
Gender Non-Conforming
Gender Fluid
Prefer not to say
Other:
Required
Are you transgender?
*
Yes
No
Prefer not to say
What's your race/ethnicity? Select all that apply.
*
Black
Latinx
Indigenous/Native American
Asian (including South and South East Asian)
White
Other:
Required
What income status would you assign yourself?
*
Poor
Working class
Middle class
Upper class
Rich
Other:
Do you prefer or need to receive medical care in a language other than English? If so, which language?
*
Your answer
What are some reasons that you have changed certain health care providers or chose not to go back? In describing your experience, please include the type of provider (therapist, OBGYN, dentist, etc).
*
Your answer
What makes you continue going to certain health care providers? In describing your experience, please include the type of provider (therapist, OBGYN, dentist, etc).
*
Your answer
When receiving health care, are traditional healing practices important to you?
*
Your answer
What are some traditional healing practices, such as yoga, reiki, acupuncture, massage, that you follow or receive, if any?
Your answer
Have any health care providers been encouraging of you seeking traditional healing methods other than or along with Western medicine such as pharmaceutical drugs, surgery, chemotherapy, radiation?
*
Always
Often
Sometimes
Rarely
Never
Have any health care providers sought permission before they touched you?
*
Always
Often
Sometimes
Rarely
Never
If applicable, have any health care providers called you by your dead name or the name you were assigned at birth?
*
Always
Often
Sometimes
Rarely
Never
Not applicable
Have you had the option to put down your sexual orientation, gender and/or preferred name on intake forms?
Always
Often
Sometimes
Rarely
Never
Clear selection
What are some details that make you feel like medical intake forms are inclusive of gender, sexual orientation and race?
*
Your answer
Have any health care providers suggested you lose weight, even when it was unrelated to the reason why you made the appointment?
*
Always
Often
Sometimes
Rarely
Never
How do your health care providers approach your physical health?
*
Your answer
How do your health care providers approach your mental health?
Your answer
Do any of your health care providers acknowledge if and when they are wrong?
*
Always
Often
Sometimes
Rarely
Never
Not applicable
How frequently have you felt any of your health care providers take their time during an appointment?
*
Always taken their time
Mostly taken their time
Sometimes taken their time
Rarely taken their time
Never taken their time
Have any health care providers ordered tests that you thought were unnecessary? If so, why do you think they were unnecessary?
*
Your answer
Have you spent time during your appointment with a health care provider educating them on who you are, your needs, and how to serve you?
*
Always
Often
Sometimes
Rarely
Never
If you have experienced any trauma, have you spoken to any of your health care providers about it? Did that provider take your trauma into consideration when treating you?
*
Your answer
Have the staff at your health care providers' offices been rude or inconsiderate of you? If so, how?
*
Your answer
What can your health care providers do to make you feel more comfortable and safe?
*
Your answer
Is there anything that hasn't been covered in the survey that impacts your access to care that you would like to share?
Your answer
Thank you so much for your time! Please share with other QPOC folks if you can. :)
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