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:
 
 
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)
 
HIV Counseling and Testing Site
 
STD Clinic
 
STD/HIV Combined Program
 
HIV Care/Case Management Clinic
 
TB Program
 
Family Planning Clinic
 
FQHC
 
Alcohol/Substance Abuse Treatment Center
 
Methadone Clinic
 
Correction Facility/Jail/Prison
 
Communicable Diseases Program
 
Other (Please Specify)
    

 
 
 
Hepatitis Activities
 
 
HEPATITIS TESTING

1. Indicate what type(s) of hepatitis testing your program provides. (Select all that apply)
 
Hepatitis B (HBsAG test)
 
Hepatitis C (antibody test)
 
None (go to question 4)
 
Other (Please Specify)
    

 
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?
 
Yes
 
No
 
 
Comments/Concerns:
   
 
 
ADULT HEPATITIS VACCINATIONS

1. Does your program offer hepatitis vaccinations? (Select all that apply)
 
Hepatitis A
 
Hepatitis B
 
Hepatitis A/B
 
No (go to question 3)

 
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?
 
Yes
 
No
 
 
Comments/Concerns:
   
 
 
OTHER HEPATITIS ACTIVITIES

1. Does your program offer viral hepatitis education materials appropriate for your target population?
 
Yes
 
No
 
 
2. Does your program make referrals for hepatitis testing, vaccination and other services?
 
Yes
 
No
 
 
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)
 
Conducting hepatitis risk assessments
 
Basic viral hepatitis
 
Hepatitis treatment options
 
Interpreting hepatitis test results
 
Integrating hepatitis prevention activities
 
Providing hepatitis test results

 
 
Resources for: (Select all that apply)
 
Hepatitis Vaccines
 
Hepatitis Tests
 
Additional personnel
 
Other (Please Specify)
    

 
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.
Survey Software Powered by QuestionPro Survey Software