IMPLEMENTATION GUIDE TOOLKIT
FEEDBACK & AUDIT
PART I
PROVIDER SURVEY OF FAMILY PLANNING PRACTICES
This survey is an example of a tool that assesses knowledge or practice gaps among clinical providers. Consider adap-
tations and modifications to better fit the needs of your setting. It may be used anonymously to assess overall prac-
tices, or may be linked to individual providers to identify coaching or training needs. The accompanying interpretation
guide identifies the main concepts being evaluated and links to the MEC/SPR.
PART I. DEMOGRAPHICS
1. Which of the following describes the setting of this practice/health center?
(select all that apply)
Community clinic or health center
Family planning clinic
Health department
Hospital-based clinic
Private clinic
Other (please specify) _______________________________
2. In this practice/health center, how many health care providers, including you, provide family planning
services? _________
3. What is your role as a health care provider?
(select one)
Community health worker
Nurse
Nurse midwife
Physician
Other (please specify) ___________________
4. On average, how many female patients of reproductive age do you see per week? _________
5. Have you been trained in the insertion and removal of the following contraceptive methods for women during
routine care?
Yes No
Copper intrauterine device (Cu-IUD)?
Levonorgestrel-releasing intrauterine device (LNG-IUD)?
Contraceptive implant (Jadelle® or Nexplanon®)?
IMPLEMENTATION GUIDE TOOLKIT
FEEDBACK & AUDIT
PART I Provider Survey of Family Planning Practices
6. Have you been trained in the insertion and removal of the following contraceptive methods for women immedi-
ately postpartum?
Yes No
Copper intrauterine device (Cu-IUD)?
Levonorgestrel-releasing intrauterine device (LNG-IUD)?
PART II. CONTRACEPTIVE METHOD AVAILABILITY
7. For each method of contraception, please indicate if it is directly available from a provider or onsite source,
prescribed/recommended to obtain off-site, patients are referred offsite to other providers, or if it is not
available to patients in your practice/health center.
(in each row, select all that apply)
Not available
Directly Referred off-
Prescribed/ onsite, or by
available site to other Don’t Know
recommended prescription
onsite providers
or referral
LNG-IUD
Cu-IUD
Implant
Combined oral contraceptives
(COCs)
Progestin-only oral pills (POPs)
Injectable (DMPA-IM, DMPA-SC,
NET-EN)
Contraceptive patch
Vaginal ring
Diaphragm
Male condom
Female condom
Emergency contraceptive pills
Cu-IUD as emergency
contraception
IMPLEMENTATION GUIDE TOOLKIT
FEEDBACK & AUDIT
PART I Provider Survey of Family Planning Practices
PART III. PROVIDER PRACTICES
8. In the past month, how often have you (or your clinical team) provided intrauterine devices (Cu-IUDs or LNG-
IUD) to nulliparous women?
Very often or often Go to question #9.
Not often or never Please indicate why. (select all that apply)
I rarely have nulliparous women as patients
IUDs are generally unavailable in my practice/health center
I am concerned about the safety of IUDs for nulliparous women
I am concerned about the effects on future fertility
I am concerned about difficult insertion
I am not trained in IUD insertion
My nulliparous patients generally prefer a different method
My practice/health center protocol does not allow it
Other reasons (please specify) _____________________________________________
9. Before initiating the following contraceptive methods, please indicate if you or your practice/health center
require the following exams and tests for a healthy patient.
(Many of these exams and tests are appropriate for preventive health care. Here we are asking about exams and
tests that are required related to safe initiation of a contraceptive method. If the method is not offered/not avail-
able in your practice/health center, please mark the appropriate box.)
Test or exam Combined Progestogen- DMPA or NET- Implants Intrauterine
Pills only pills EN injection Devices
Not available
Blood pressure
Weight
Breast exam
Pelvic exam
Cervical cytology
(Papanicolaou smear)
STI risk assessment
HIV screening
IMPLEMENTATION GUIDE TOOLKIT
FEEDBACK & AUDIT
PART I Provider Survey of Family Planning Practices
10. In the past year, when providing or prescribing combined hormonal contraceptives (COCs, patch, ring), how
often did you start a woman on the day of her visit regardless of the timing of her menses (‘Quick Start’) if you
were reasonably certain she was not pregnant? Please answer for both adolescents and adults.
(10A) ADOLESCENTS (10B) ADULTS
Very often Very often
Go to question #10B Go to question #11
or often or often
Not often Please indicate why below. Not often Please indicate why below.
or never (select all that apply) or never (select all that apply)
I do not think it is safe I do not think it is safe
I have liability concerns I have liability concerns
I do not have enough training I do not have enough training
I do not think it is appropriate for adolescents I do not think it is appropriate for adults
Protocols do not allow it Protocols do not allow it
Other (please specify) Other (please specify)
_______________________________________ _______________________________________
_______________________________________ _______________________________________
11. In the past year, when providing DMPA or NET-EN injections, how often did you start a woman on the day of
her visit regardless of the timing of her menses (‘Quick Start’) if you were reasonably certain she was not
pregnant? Please answer for both adolescents and adults.
(11A) ADOLESCENTS (11B) ADULTS
Very often Very often
Go to question #11B Go to question #12
or often or often
Not often or Please indicate why below. Not often or Please indicate why below.
never (select all that apply) never (select all that apply)
I do not think it is safe I do not think it is safe
I have liability concerns I have liability concerns
I do not have enough training I do not have enough training
I do not think it is appropriate for adolescents I do not think it is appropriate for adults
Protocols do not allow it Protocols do not allow it
Other (please specify) Other (please specify)
____________________________________ _____________________________________
____________________________________ _____________________________________
IMPLEMENTATION GUIDE TOOLKIT
FEEDBACK & AUDIT
PART I Provider Survey of Family Planning Practices
12. In the past year, when providing an intrauterine device (Cu-IUD or LNG-IUD), how often did you start a
woman on the day of her visit regardless of the timing of her menses (‘Quick Start’) if you were reasonably
certain she was not pregnant? Please answer for both adolescents and adults.
(12A) ADOLESCENTS (12B) ADULTS
Very often or Very often or
Go to question #12B Go to question #13
often often
If “not often or never” please If “not often or never” please
Not often or Not often or
indicate why below. indicate why below.
never never
(select all that apply) (select all that apply)
IUDs are unavailable in my IUDs are unavailable in my practice/health center
practice/health center
I do not think it is safe I do not think it is safe
I have liability concerns I have liability concerns
I do not have enough training I do not have enough training
I do not think it is appropriate for adolescents I do not think it is appropriate for adults
Protocols do not allow it Protocols do not allow it
Other (please specify) Other (please specify)
________________________________________ ________________________________________
________________________________________ ________________________________________
13. In the past year, when providing an implant, how often did you start a woman on the day of her visit re-
gardless of the timing of her menses (‘Quick Start’) if you were reasonably certain she was not pregnant?
Please answer for both adolescents and adults.
(13A) ADOLESCENTS (13B) ADULTS
Very often Very often
Go to question #13B Go to question #14
or often or often
If “not often or never” please If “not often or never” please
Not often or Not often or
indicate why below. indicate why below.
never never
(select all that apply) (select all that apply)
Implants are unavailable in my practice/health Implants are unavailable in my practice/health
center center
I do not think it is safe I do not think it is safe
I have liability concerns I have liability concerns
I do not have enough training I do not have enough training
I do not think it is appropriate for adolescents I do not think it is appropriate for adults
My practice/health center protocol does not allow it My practice/health center protocol does not allow it
Other (please specify) Other (please specify)
_________________________________________ _________________________________________
_________________________________________ _________________________________________
IMPLEMENTATION GUIDE TOOLKIT
FEEDBACK & AUDIT
PART I Provider Survey of Family Planning Practices
14. Do patients in your practice/health center routinely undergo a urine pregnancy test before starting a con-
traceptive method?
Yes No
15. When can a woman initiate these contraceptive methods? (Check all boxes that apply.)
Oral contracep- DMPA or NET- Implants Intrauterine
tives (all types) EN injection Devices
Any time as long as reasonably sure
the woman is not pregnant
Within 7 days after start of normal
menses
On the same day after abortion
16. In the past month, how often have you not been able to provide a women with a contraceptive method at
the time that she desired?
Please indicate why below.
Very often or often
(select all that apply)
Not often or never Go to question #17.
Her chosen method was not available at that time
She had a medical condition that prevented her from receiving the method.
She was not on her menses and could not start the method.
I was concerned that she could be pregnant.
She required further examinations or testing before she could start.
I am not trained in the method that she chose.
Other reasons (please explain) ________________________________________________
17. In the past month, when counseling your typical female patient of reproductive age on family planning, how
often have you (or your clinical team) done the following?
Very often Often Not often Never
Counseled patient on how to correctly use their contra-
ceptive method.
Counseled patient on what to do if late or missed dose.
Helped the patient think about potential barriers to using
their selected method(s) correctly and developed a plan
to deal with these barriers.
Counseled patient on possible changes in menstrual
bleeding.
Counseled on return to fertility after discontinuing a
method.
Counseled patient on what to do if interested in discon-
tinuing or switching methods.
Counseled on how to obtain emergency contraception.
Counseled on condom use to prevent STDs.
