SKILLS & EXPERIENCE INVENTORY

Name: _____________________________

Training Program: __________________________

I. TRAINING – Have you ever had training in:

1. Family Planning/Contraception	[ ] Yes	[ ] No	Hours: _______
2. Unintended Pregnancy & Options Counseling	[ ] Yes	[ ] No	Hours: _______
3. Miscarriage Management	[ ] Yes	[ ] No	Hours: _______
4. Public Health Aspects of Abortion Access	[ ] Yes	[ ] No	Hours: _______

II. EXPERIENCE – check all of which apply:

NUMBER OF PROCEDURES/SESSIONS:

Electric Vacuum Aspiration (EVA)	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30
Manual Vacuum Aspiration (MVA)	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30
Dilation & Curettage	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30
Ultrasound dating	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30
Medical management of miscarriage	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30
IUD insertion	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30
Contraceptive implant insertion	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30
Prenatal care	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30
Early pregnancy dating exams	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30
Endometrial biopsy	[ ] 1-10	[ ] 11-20	[ ] 21-30	[ ] >30

III. ADDITIONAL INFORMATION

I. Could you give me three reasons why you decided to participate in this Training Program?

_____________________________________________________________

II. Do you have any hesitations about participating in this Training Program or providing abortions?

[ ] Yes [ ] No

III. Aside from technical skills, do you anticipate any other benefits from completing this training?

_____________________________________________________________

IV. Do you anticipate offering abortions in future practice?

[ ] Yes [ ] No

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