Survey Platform

PATA Client Satisfaction Scorecard

At this health facility we are dedicated to ensuring that young people like yourself feel comfortable and well cared for. That's why we want to hear from you about your experiences with us. If you're between the ages of 10-24 years, please fill out this scorecard to let us know how we're doing.

1. Name of health facility visited

2. Region/District of health facility

3. Country

4. Do you agree to complete this client satisfaction scorecard? *

YesNo

5. Age

6. How would you like us to address you?

FemaleMaleOther

7. Please tick if any of these apply to you.

I am sexually activeI am a young person who exchanges sex for money, phone, food, clothes etcI am a young person with physical disabilitiesI am a young person who uses drugsI am not sexually activePrefer not to say

8. Has this form been completed together with a parent or caregiver?

YesNo

9. Has this form been completed together with a peer supporter?

YesNo

10. Do you know if your health facility offers the following HIV/sexual reproductive health services and commodities:

11. Useful materials on HIV and sexual reproductive health rights (SRHR), such as posters, leaflets, flyers, were made available to me.

YesNoDo not know

12. The health facility connects me with a support group.

YesNoDo not know

13. The health facility (including surroundings) is clean.

14. I am involved in the decisions regarding my care and can make my own choices.

15. The health facility provides me with self-care SRHR services through digital platforms (e.g., chat groups for peer support, medication reminders via mobile phone).

16. Are there any other observations and/or experiences you would like to share?