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?

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IV. Do you anticipate offering abortions in future practice?

[ ] Yes   [ ] No