PATA Client Satisfaction Scorecard

Name of health facility visited

Region/District of health facility

Country

Do you agree to complete this client satisfaction scorecard? *

Yes No

Age

How would you like us to address you?

Female Male Other

Please tick if any of these apply to you.

I am sexually active I am a young person who exchanges sex for money, phone, food, clothes etc I am a young person with physical disabilities I am a young person who uses drugs I am not sexually active Prefer not to say

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

Yes No

Has this form been completed together with a peer supporter?

Yes No

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

	Yes	No	Do not know
Oral contraceptive
Emergency contraception
Contraceptive patch
Vaginal ring
Self-injectable
Long lasting contraceptive
Diaphragm
Male condoms
Female condoms
Safe abortion services
HIV self-testing
STI self-testing
Pre-exposure prophylaxis
Post-exposure prophylaxis
HIV treatment (ART)
STI self-medication

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

Yes No Do not know

The health facility connects me with a support group.

Yes No Do not know

The health facility (including surroundings) is clean.

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

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).

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

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