Provider Survey Cover Sheet

This survey is being sent to a selected sample of health centers and providers. Please do not distribute to others for completion.

Form Approved

OMB Number: 0920-XXXX

Expiration Date: XX/XX/XXXX

2012 – 2013 SURVEY of HEALTH CARE PROVIDERS

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).

Be assured that your responses will be maintained in a secure manner. This survey has been approved by the Centers for Disease Control and Prevention as non-research public health practice.

Please return this survey as soon as possible. Use the enclosed postage paid envelope. You may also complete the survey online (see instructions below).

To determine if you are eligible to participate in this survey, please answer the

following question:

Do you provide family planning services* to at least two women of reproductive age per

week?

Yes If you answered yes, please continue and complete the survey.

No If you answered no, you may stop here. Please return the survey in the

envelope provided so we can remove you from our list. Thank you for your time.

* For the purpose of this survey, a family planning service is any service related to postponing or preventing pregnancy. Family planning services may include a medical examination related to provision of a method, contraceptive counseling, method prescription or supply visits. A patient may receive a family planning service even if the primary purpose of the visit is not for contraception.

To complete the survey online:

I

Insert Survey

ID Here

f you wish to complete the survey online, use your internet browser to go the home page at: www.<insert_website_here>.org. Only authorized users may complete the survey and your unique username and password are provided below. The web survey is conducted from a “secure” https (SSL) service using the same type of internet security as is used for handling credit card transactions.

Use this unique username and password below to access the survey:

Your username is: <username>

Your password is: <password>

Insert Survey

ID Here