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* 1. Practice Name:

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* 2. Address(es)

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* 3. What is your practice specialty/subspecialty?

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* 4. Facility training representative or administrator name:

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* 5. Facility representative or administrator phone number:

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* 6. Facility training representative or administrator email address:

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* 7. Approximately how many clinical staff does your practice employ?

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* 8. Approximately how many non-clinical staff does your office employ?

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* 9. Do you offer training specific to LGBTQ+ competent healthcare to both your non-clinical and clinical staff?

If you already do this, you are halfway there to being a Pride in Our Health Provider! 

If you need support in finding trainings, please select “no, but we are interested and would like more information”. When you complete this survey, you will be provided with a list of training resources that apply.

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* 10. Does your facility have a patient nondiscrimination policy that includes language around sexual orientation and gender identity?

If you have this, you're halfway there to becoming a Pride in Our Health Provider!

If you need support in putting together this document, please select “no, but we are interested and would like more information” and someone will contact you with support on creating a policy.

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* 11. If you responded yes to the last question, please indicate how this policy is communicated to patients. Otherwise, please skip.

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* 12. Does your facility have an equal visitation policy?

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* 13. Please select what information your intake forms collect. If your intake forms collect any of the below information, please upload and send a copy to PrideInOurHealth@yavapaiaz.gov

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* 14. If yes, are you using the above information for patient care, insurance purposes, and/or billing?

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* 15. Do your intake forms offer nongendered questions around OBGYN information?

For example, instead of only asking female patients to answer when their last menstruation was, ask all patients and give them the option to choose "not applicable".

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* 16. Do your intake forms offer questions around family/spouse relationships that are inclusive of all types of families?

For example, instead of only giving a patient the option to state "single, widowed, married, separated, and divorced", you can also give them the option to select that they are "cohabitating with a partner".

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* 17. Optional: Do any of your clinicians self-identify as a member of the LGBTQ+ community?

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* 18. For inpatient facilities, and publicly funded and/or nonprofit practices only, do you participate in the Human Rights Campaigns Health Equality Index?

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