Fill | Druk CLM

Section 1: HIV/ Health Service and Visit Date

1. Today's Date *

2. Date of Clinic Visit *

3. Location of the facility (Dzongkhag) *

4. Region *

5. Facility Name *

Section 2: Feedback on the service [Tick each option]

6. Which service(s) did you seek in the last six months? If Yes, did you receive it?

6a. Condom supply sought? *

Yes

6a. Condom supply received?

Yes

6b. Lubricant supply sought? *

Yes

6b. Lubricant supply received?

Yes

6c. HIV Testing sought? *

Yes

6c. HIV Testing received?

Yes

6d. HIV Confirmation Test sought? *

Yes

6d. HIV Confirmation Test received?

Yes

6e. HIV counseling sought? *

Yes

6e. HIV counseling received?

Yes

6f. STI testing/diagnosis sought? *

Yes

6f. STI testing/diagnosis received?

Yes

6g. Antiretroviral therapy(ART) Initiation sought? *

Yes

6g. Antiretroviral therapy(ART) Initiation received?

Yes

6h. Antiretroviral therapy (ART) Counselling Sought? *

Yes

6h. Antiretroviral therapy (ART) counselling received?

Yes

6i. Antiretroviral therapy (ART) Refill sought? *

Yes

6i. Antiretroviral therapy (ART) refill received?

Yes

6j.Other STI Treatment sought? *

Yes

6j.Other STI Treatment received?

Yes

6k. Viral Load Testing sought? *

Yes

6l. Viral Load Testing received?

Yes

6l. CD4 Testing Sought? *

Yes

6l. CD4 Testing receive?

Yes

6m. Opportunistic infection management and medicine sought? *

Yes

6m. Opportunistic infection management and medicine received?

Yes

6n. Detoxification for drugs and alcohol sought? *

Yes

6n. Detoxification for drugs and alcohol received?

Yes

6o.Rehabilatition services for drugs and alcohol sought? *

Yes

6o.Rehabilatition services for drugs and alcohol received?

Yes

6p.Hospital based SUD treatment sought? *

Yes

6p.Hospital based SUD treatment received?

Yes

6q. Other HIV services sought? *

Yes

6q. Other HIV services received?

Yes

Please specify other HIV services

6r. TB Services Sought? *

Yes

6r. TB Services received?

Yes

6s. Other Health conditions [Services sought]? *

Yes

6s. Other Health conditions [Services received]?

Yes

Please specify other health conditions services

7. Was the service location safe for you *

Yes

8. Was the location not very far or hard to travel to? *

Yes

9. Are the opening hours and days of operations okay for you? *

Yes

10a. Did you incur any out-of-pocket expense while availing the health services? (if yes - please look at questions 10b) *

Yes

10b. What did you have to spend money on to receive the health services (i.e. travel, supplement medication, logistics)?

10c. If yes, were you able to afford these services?

Yes

11. Were you treated respectfully by the staff, regardless of your gender, sexual orientation, age or religion, HIV status, and Profession (applicable for SW only)? *

Yes

12. Did the staff/health care provider seek your consent for any procedures (examinations, tests, etc.)? *

Yes

13. Did you receive all the information you need? *

Yes

14. Were all your questions answered and clarified properly? *

Yes

15.Did you receive the items (medicine, condoms, information, lubricant, etc.) you need/require? *

Yes

16. How long did you have to wait to see the health care provider? (In Minutes) * ?

18. Out of 5, how would you rate your satisfaction level? [Where 1 is for lowest and 5 is for highest satisfaction where 5= Very satisfied and 1= very dissatisfied] *

Section 3: Reports of any serious incidents experienced [Select all that apply]

19. Did you experience any of the following at or linked to the visit?

19a. Stigma and discrimination (negative attitude towards you or treated you unfairly by health worker during your visit because of your identity as Key Population) *

Yes

19b. Violence (such as verbal abuse, physical abuse, sexual abuse, negligence by staff or person at the health facility) *

Yes

19c. Harassment (including sexual) from the service staff or other clients *

Yes

19d. Breach of privacy (physical privacy maintained) *

Yes

19e. Breach of confidentiality (was your information shared with others without your consent) *

Yes

19f. Refused service because of gender, identity case, risk behaviors or other. *

Yes

19g. Physical pain or mental distress *

Yes

19h. Other *

Yes

Specify

20. Can you please provide some more details to assist our follow-up?

21. Do you consent to having a trained staff member or volunteer contact you to help resolve this?

Yes

22. Please provide your preferred mode of contact and details (Phone Number)

Section 4. Client Profile

23. When did you last complete this form? *

Never

Less than 6 months ago

More than 6 months ago

24. What is your age? *

25. What is your gender? *

26. Please select any Key Population identity you belong to (you may select more than 1):

Men who have sex with men

Sex worker

Transgender person

People who use drugs and alcohol

People living with HIV

Do not want to disclose

27. What was the best part of your experience(s) at this health facility while availing service?