FQHC Baseline Survey

MOMCHA PROGRAM

FQHC BASELINE SURVEY

PURPOSE: The purpose of this survey is to have an understanding of the FQHC's utilization and understanding of doulas.

ESTIMATED TIME TO COMPLETE: 3 minutes

INSTRUCTIONS: Please answer honestly and completely. When selecting an OTHER checkbox, please enter text in the box provided.
BorinquenJessie TriceMiami BeachCHIEmpowerUOther
What is your role at your FQHC?
I. DOULA SERVICES: EDUCATION AND AWARENESS
YESNOSomewhat
YESNOSomewhat
YESNOSomewhat
What services do they provide?What is their role in the pregnancy team?What are their qualifications?Other
Journal publications/peer-reviewed articlesSocial media (e.g., Facebook, Instagram, Twitter)Other providersOther
YESNOSomewhat
Billing and ReimbursementContractingUnaware of doula benefitsOther
II. DOULA CARE COORDINATION AND REFERRALS
8. What are the characteristics of a good labor support team?
YESNOPLANNING TO OFFER IN THE FUTURE
YESNO
YESNO
YESNOSomewhat
1-2 times3-4 times4+ or more timesNever referred
Pre-conception or interconception (family-planning state)1st Trimester2nd Trimester3rd trimesterBirthPost-Partum
Direct (Phone call or online: Provider contacts doula service for follow-up; Patient provided follow up from doula service)Indirect (Patient contacts doula or doula service to make an appointment, phone call or online)Other: Please provide method of referral (open text)Other
YESNO
YESNOSometimes
Very likelySomewhat likelyI do not feel comfortable with including a doula on the pregnancy teamI do not see the need for a doula or their servicePrevious doula services did not show any benefit to continuing services
Should be Empty: