“No Wrong Doors – No Missed Opportunities”

Healthcare provider Practice - Self-Assessment

Please Circle -1 is high, 2 is moderate, and 3 is low
POLICY / Policy in Place / Support Staff (RN, LPN, Front-Desk) / Physician/Clinician Staff
Awareness / Ability to Implement / Awareness / Ability to Implement
Adolescent Confidentiality / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Time Alone with Provider at Preventive Care Visits / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Time Alone with Provider at Acute Care Visits / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Initiate Sexual Health Assessment by age 12 / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Update Sexual Health Assessment at every visit (acute/preventive) / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Present for sexual health care without parent/caregiver / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Ensure that adolescents are not turned away when they request sexual health services but can’t pay / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
REPRODUCTIVE HEALTH SERVICES / Service Available / Support Staff (RN, LPN, Front-Desk) / Physician/Clinician Staff
Awareness / Ability to Implement / Awareness / Ability to Implement
Hormonal Contraceptive Available and Dispensed on-site / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Hormonal Contraceptive Available Rx / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
IUD Available and Provided to Adolescents on-site / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Implant Available and Provided to Adolescent on-site / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Contraception Provided without Requiring a Pelvic Exam / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Emergency Contraception available and dispensed on-site / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
REPRODUCTIVE HEALTH SERVICES
cont. / Service Available / Support Staff (RN, LPN, Front-Desk) / Physician/Clinician Staff
Awareness / Ability to Implement / Awareness / Ability to Implement
Emergency Contraception Rx available / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Emergency Contraception provided in advance on -site / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Testing for Chlamydia and Gonorrhea utilizing urine technology / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
HIV Rapid Testing Available / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Address Sexual Health Needs of Males / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Provision of Contraception and STD/HIV Testing for Adolescents Without Requirement of Parental Consent / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
TOOLS TO SUPPORT IMPLEMENTATION / In Place / Support Staff (RN, LPN, Front-Desk) / Physician/Clinician Staff
Awareness / Ability to Implement / Awareness / Ability to Implement
Does your practice routinely inform families and teens the practice's policy of confidentiality before the practice of confidentiality (when making an appointment, and when they present for care) / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Letter/Fact Sheet provided to parent/caregivers describing approach to the delivery of services to adolescents that supports delivery of confidential sexual health services and time-alone / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Letter/Fact Sheet given to adolescents describing sexual health services available without parental consent / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Posters or brochures in the waiting area explaining adolescent consent and confidentiality and your policy / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Standardized patient visit forms that include sexual health assessment questions / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure
Patient Self-Assessment and History Forms that include sexual health assessment questions / Yes / No / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure / 1 / 2 / 3 / Not Sure

CAI (Cicatelli Associates Inc) April 2013 1