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Student Health and Counseling Center
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STUDENT HEALTH AND COUNSELING CENTER
1.
Q1
In the last 12 months, have you received any health services through the Student Health Center on
campus?

Yes
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
2.
Q2
3.
Q3
4.
Q4
5.
Q5
6.
Q6
No
In the last 12 months, have you received any counseling or psychological services through the Student
Health Center on Campus?
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Yes
No
Are you currently covered by major medical insurance through your employment, through your spouse
or parents, or through a government program?
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Yes
No
Don't Know
Does your insurance plan require prior authorization to receive medical services from an entity other
than your regular health care provider or limit your visits to only approved locations and providers?
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Yes
No
Don't Know
Does your insurance plan have deductibles of $500 or more per year and/or copays of $15 or more per
visit?
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Yes
No
Don't Know
You indicated that you have not used any health services through the student health center in the last 12
months. Please indicate why not. (Check all that apply)
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Have not needed to use it
Did not know about the services
Used my own medical provider
Thought I had to have insurance to use it
Had a bad experience there before
Had heard bad things about it from others
Had to wait too long for an appointment to see someone
Hours are not compatible with my schedule
Did not know where the health center was located.
Concerns about confidentiality
Concerns about what others might think
Did not know there is no charge for basic medical visits
Decline to answer
Other
(Other Describe: If you have not received health services at your campus, please indicate why not.)
Q6a
__________________________________________________________________________________
_________________________
7.
You indicated that you have not used counseling or psychological services through student health
services in the last 12 months. Please indicate why not. (Check all that apply)
Q7
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Have not needed to use it
Did not know about the services
Used my own mental health professional
Thought I had to have insurance to use it
Had a bad experience there before
Had heard bad things about it from others
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Had to wait too long for an appointment to see someone
Hours are not compatible with my schedule
Did not know where the health center was located.
Concerns about confidentiality
Concerns about what others might think
Did not know there is no charge for basic visits
Decline to answer
Other
(Other Describe: If you have not received counseling or psychological services at your campus, please indicate why not.)
Q7a
__________________________________________________________________________________
_________________________
Knowledge of Services
8.
Q8a
Q8b
Q8c
Q8d
Q8e
Q8f
Q8g
Q8h
Q8i
Q8j
Q8k
Q8l
Q8m
Before taking this survey, did you know that...
...most basic services are pre-paid by
your Student Health Fee.
...there is no additional charge for basic
medical visits at the student health
center.
...health center records are confidential
and that your information cannot be
released without your consent, even to
your family members.
...we have male healthcare providers on
staff and that we offer men's health
services.
...we have female healthcare providers
on staff and that we offer women's
health services.
...you can request appointments with
the physician or nurse practitioner of
your choice.
...you can get free, anonymous HIV
testing onsite.
...we have an onsite pharmacy for low
cost prescriptions.
...our onsite pharmacy also sells
over-the-counter (no prescription
needed) medications.
...counseling and psychological services
are pre-paid by your Student Health
Fee.
...counseling and psychological records
are confidential and are not part of your
academic record or health services
records
...we offer couples counseling.
...there is a low cost private health
insurance plan available through
Associated Students that supplements
the basic services offered by our health
center, to cover things such as
hospitalization, ambulance and after
hours emergencies.
Yes
No
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9.
What can we do to better communicate student health or counseling and psychological services to you?
Q9
__________________________________________________________________________________
_________________________
Return survey to: anaiknimbalkar@calstate.edu
You indicated that you have used health services in the last 12 months.
10.
Q10
11.
Q11
12.
Q12
13.
Q13
Approximately how many times have you visited student health services in the past 12 months?
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1 to 3 times
4 to 6 times
7 or more times
Approximately when was your most recent visit?
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May 2012
June 2012
July 2012
August 2012
September 2012
October 2012
November 2012
December 2012
January 2013
February 2013
March 2013
April 2013
May 2013
Overall, how satisfied are you with student health services?
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Very Dissatisfied
Dissatisfied
Neutral
Satisfied
Very Satisfied
Don't Know
Based on your experience, how likely are you to recommend student health services to a friend?
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Definitely Would Not
Probably Would Not
Might or Might Not
Probably Would
Definitely Would
STUDENT HEALTH AND COUNSELING CENTER
14.
Please rate your level of satisfaction with the following. If you cannot rate the item, or it's not applicable,
select "Don't Know / NA".
Very
Dissatisfie
Dissatisfie
d
d
Q14a
Ability to get appointment time when you
wanted it
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Neutral

Satisfied

Very
Don't
I have not
Satisfied Know / NA made an
appointme
nt for my
visits to
the health
center
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

Return survey to: anaiknimbalkar@calstate.edu
15.
Q15
16.
Was your most recent visit with a physician or a nurse practitioner?

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Physician
Nurse Practitioner
I'm not sure
Please rate your level of satisfaction with the following items. If you cannot rate the item, or it's not
applicable, select "Don't Know / NA".
Very
Dissatisfied
Dissatisfied


Neutral
Satisfied
Very
Satisfied
Don't Know /
NA
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Q16a
How well he or she explained your
medical condition.
17.
For your most recent visit, did you make an appointment, or did you walk-in without an appointment?
Q17
18.
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I made an appointment
I walked-in without an appointment
Please rate your level of satisfaction with the following items. If you cannot rate the item, or it's not
applicable, select "Don't Know / NA".
Very
Dissatisfied
Dissatisfied
Q18a
Q18b
For your most recent visit, how satisfied
were you with the amount of time it took
from when you initially checked in until
when the physician or nurse practitioner
arrived to see you.
Overall, how satisfied were you with
your most recent visit?
Neutral
Satisfied
Very
Satisfied
Don't Know /
NA
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STUDENT HEALTH AND COUNSELING CENTER
19.
Please indicate your level of satisfaction with the service provided by the following individuals during
your visits to Student Health Services. If you did not have service from an individual, select "Don't Know /
NA."
Very
Dissatisfied
Dissatisfied
Q19a
Q19b
Q19c
Q19d
Q19e
Q19f
Q19g
Q19h
Q19i
Q19j
Q19k
Q19l
Q19m
Q19n
Q19o
Q19p
Q19q
Q19r
Q19s
Q19t
Q19u
Front Desk Staff
Receptionist
Triage Nurse
Clinical Assistants / Nursing Staff
Immunization / Screening Nurse
Physician
Nurse Practitioner
Laboratory staff
X-Ray Technologist
Pharmacist
Pharmacy Technician
Cashier
Nutritionist
Physical Therapist
Sports Rehabilitation
Orthopedic Surgeon
Sports Medicine Specialist
Health Educator
Family PACT Coordinator
Chiropractor
Acupuncturist
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Neutral
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Satisfied
Very
Satisfied
Don't Know /
NA
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Return survey to: anaiknimbalkar@calstate.edu
Q19v
Q19w
Q19x
Dentist
Massage Therapist
Optometrist
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STUDENT HEALTH AND COUNSELING CENTER
20.
Q20
21.
Have you received Family P.A.C.T. Services through the Student Health and Counseling Center during
the past 12 months?


Yes
No
You indicated that you have received Family P.A.C.T. Services. If you cannot rate the item, or it is not
applicable, select "Don't Know / NA".
Very
Dissatisfied
Dissatisfied
Q21a
Q21b
Q21c
Q21d
How well your personal privacy and
dignity were respected.
How well you were given a freedom of
choice in selecting a contraceptive
method.
The adequacy of verbal and written
information we provided.
Family PACT Coordinator.
Neutral
Satisfied
Very
Satisfied
Don't Know /
NA
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STUDENT HEALTH AND COUNSELING CENTER
You indicated that you have used counseling or psychological services
in the last 12 months.
22.
Approximately how many visits have you had in the past 12 months?
Q22
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23.
Q23
24.
Q24
1 to 3 times
4 to 6 times
7 or more times
Approximately when was your most recent visit?
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May 2012
June 2012
July 2012
August 2012
September 2012
October 2012
November 2012
December 2012
January 2013
February 2013
March 2013
April 2013
May 2013
Overall how satisfied are you with counseling or psychological services?


Very Dissatisfied
Dissatisfied
Return survey to: anaiknimbalkar@calstate.edu




25.
Q25
26.
Neutral
Satisfied
Very Satisfied
Don't Know
Based on your experience, how likely would you be to recommend counseling or psychological services
to a friend?





Definitely Would Not
Probably Would Not
Might or Might Not
Probably Would
Definitely Would
Please rate your level of satisfaction with the following. If you cannot rate the item, or it's not applicable,
select "Don't Know / NA".
Very
Dissatisfie
Dissatisfie
d
d

Neutral

Satisfied

Very
Don't
I have not
Satisfied Know / NA made an
appointme
nt for my
visits to
the health
center


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
Q26a
Ability to get appointment time when you
wanted it
27.
For your most recent visit, did you make an appointment, or did you walk-in without an appointment?
Q27


I made an appointment
I walked-in without an appointment
STUDENT HEALTH AND COUNSELING CENTER
28.
Please rate your level of satisfaction with the following aspects of counseling and psychological
services. If you cannot rate the item, or it's not applicable, select "Don't Know / NA".
Very
Dissatisfied
Dissatisfied
Q28a
Q28b
For your most recent visit, how satisfied
were you with the amount of time it took
from when you initially checked in until
when the counselor or psychologist
arrived to see you.
Overall, how satisfied were you with
your most recent visit?
Neutral
Satisfied
Very
Satisfied
Don't Know /
NA
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STUDENT HEALTH AND COUNSELING CENTER
29.
Q29
30.
Did you see a....
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Counselor
Psychologist
Psychiatrist
Graduate Student Trainee
I am not sure what their title was.
Please rate your level of satisfaction with the following aspects of counseling and psychological
services. If you cannot rate the item, or it's not applicable, select "Don't Know / NA".
Very
Dissatisfied
Dissatisfied
Neutral
Satisfied
Very
Satisfied
Don't Know /
NA
Return survey to: anaiknimbalkar@calstate.edu
Q30a
Q30b
Q30c
31.
How well he or she explained your
psychological condition.
How helpful he or she was.
If you had cultural specific issues, how
appropriately they were addressed
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Please rate your level of satisfaction with the following aspects of counseling and psychological
services. If you cannot rate the item, or it's not applicable, select "Don't Know / NA".
Very
Dissatisfied
Dissatisfied
Q31a
Q31b
Q31c
Receptionist or front-office staff
Cashier
Location of the clinic
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Neutral
Satisfied
Very
Satisfied
Don't Know /
NA
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Student Health or Counseling Services
32.
Q32
Where do you go to find information regarding the clinic's services, hours, or health education
events/activities? (Check all that apply.)

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Flyers
Student Health and Counseling Center website
Campus Newspaper
Friends/roommates
Orientation
Catalog/Class Schedule
Faculty/Staff
Other
(Other Describe: Where do you go to find information regarding the clinic's services, hours, or health education
events/activities?)
Q32a
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___
STUDENT HEALTH AND COUNSELING CENTER
33.
Please take a moment to describe what you appreciate the most or what is working well for you regarding
our services.
Q33
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________________________________
34.
Please take a moment to describe any difficulties you have had with any aspect of our services.
Q34
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________________________________
35.
What suggestions, if any, do you have for improvement of our services?
Return survey to: anaiknimbalkar@calstate.edu
Q35
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________________________________
36.
Please use the space below to add any other comment or feedback you wish to make.
Q36
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________________________________
37.
Please use the space below to add any other comment or feedback you wish to make.
Q37
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________________________________
STUDENT HEALTH AND COUNSELING CENTER
38.
Q38
39.
Q39
40.
Q40
Based on the number of academic units you have completed, what is your present class level?
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Freshman - (0-44 quarter units or 0-29 semester units)
Sophomore - (45-89 quarter units or 30-59 semester units)
Junior - (90-134 quarter units or 60-89 semester units)
Senior - (135+ quarter units or 90+ semester units)
Graduate, Postbaccalaureate
Decline to answer
If you are currently employed, on average, how many hours per week do you work on your job(s)?

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Not Working
1 - 10 hours
11- 20 hours
21 - 30 hours
31 - 40 hours
More than 40 hours
Decline to answer
Race/Ethnicity
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White Only, Not Hispanic
Black Only, Not Hispanic
American Indian Only, Not Hispanic
Asian Only, Not Hispanic
Native Hawaiian/Pacific Islander only, Not Hispanic
Two Or More Races, Not Hispanic
Hispanic/Latino (Any race)
Unknown
Non-Resident Alien
Return survey to: anaiknimbalkar@calstate.edu
41.
Q41
42.
Q42
43.
Q43
44.
Q44
45.
Q45
46.
Q46
Are you primarily a:
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Day Student
Evening Student
Both day and evening student
Weekend Student
Decline to answer
Do you live on or off campus?
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
On campus
Off campus
Decline to answer
What is your gender?
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
Male
Female
Decline to answer
What is your age group?
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Under 18
18-20
21-25
26-30
31-40
Over 40
Decline to answer
How many units are you taking this term?
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None
1-3
4-6
7-9
10-12
13-15
16-18
19 or more
Decline to answer
How long has it been since you first enrolled at this campus?
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New student (i.e.,this is your first term on this campus)
Less than 1 year
1 - 2 years
3 - 4 years
5 - 6 years
7 - 8 years
9 - 10 years
More than 10 years
Decline to answer
Return survey to: anaiknimbalkar@calstate.edu
STUDENT HEALTH AND COUNSELING CENTER
This survey is anonymous unless you want us to contact you and you
provide us with your contact information. If you do provide your
contact information, only your comments on this page will be
associated with your name. Your responses to individual rating
questions and other comments will not be associated with your name.
47.
Q47
Would you like us to contact you to better understand your concerns or suggestions?


Yes
No
48.
Please briefly list the topics you would like us to contact you about.
Q48
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________________________________
If you would like us to contact you, please enter your name and contact
information below.
Name
Q48a
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___
Phone
Q48b
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___
Email
Q48c
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___
49.
Campus_Name
Q49
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___
Thank you for responding to our survey. Your feedback is important
to us.
Please select the "Submit" button to complete the survey.
Return survey to: anaiknimbalkar@calstate.edu