Adult Viral Hepatitis Services Survey


In order to understand the scope of hepatitis prevention services provided to adults by programs funded by the Texas Department of State Health Services (DSHS), the following short survey was developed to be distributed and completed by selected public health venues.

Your program has been chosen to fill out the survey. Please complete by 09/16/09.



 
 
Program Name and Contact Information
 
 
 
Date:
MonthDayYear
   
 
 
Program Name/Organization:
 
Address:
 
City:
 
State
 
Zip Code:
 
 
 
Name of person completing the survey:
 
Title of person completing the survey:
 
Phone:
 
E-mail:
 
 
 
What type(s) of facility(ies) best describes your program? (Select all that apply)
 
 
 
Hepatitis Activities
 
 
HEPATITIS TESTING

1. Indicate what type(s) of hepatitis testing your program provides. (Select all that apply)
 
2. How many hepatitis tests (per month) does your program conduct?
Hepatitis B
 
Hepatitis C
 
 
3. If you specifically charge for hepatitis testing, what is your fee?
Hepatitis B
 
Hepatitis C
 
 
 
4. Is your program interested in conducting hepatitis testing?
 
 
Comments/Concerns:
 
 
 
ADULT HEPATITIS VACCINATIONS

1. Does your program offer hepatitis vaccinations? (Select all that apply)
 
2. How many hepatitis vaccinations (doses per month) does your program administer?
Hepatitis A
 
Hepatitis B
 
Hepatitis A/B
 
 
 
3. Is your program interested in providing hepatitis vaccinations?
 
 
Comments/Concerns:
 
 
 
OTHER HEPATITIS ACTIVITIES

1. Does your program offer viral hepatitis education materials appropriate for your target population?
 
 
2. Does your program make referrals for hepatitis testing, vaccination and other services?
 
 
If yes, to what program or organizations do you refer your clients?
 
 
 
 
Hepatitis Training Resources
 
 
HEPATITIS TRAINING

1. What type of training/resources does your program need in order to provide comprehensive hepatitis services?

Training on: (Select all that apply)
 
 
Resources for: (Select all that apply)
 
If you have any questions regarding this survey, please contact Larry Cuellar, Adult Viral Hepatitis Prevention Coordinator (AVHPC), at (512)533-3124 or at larry.cuellar@dshs.state.tx.us.