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