1. What is your current position at this facility? Are you a physician, nurse practitioner or physician assistant, nursing staff, clerical staff, or administrator?

1..........Physician
2..........NP, Midwife, PA, or social worker
3..........Nursing staff
4..........Clerical staff
5..........Administrator

2. How long have you been working at this facility in any position?

__________weeks __________months __________years

3. Tell us whether or not you think medication abortion pills should be available at the following places.

4. In the next year, how would you feel working in a primary care setting that offered medication abortion to women as part of their general medical care?

1..........Very comfortable
2..........Somewhat comfortable
3..........Somewhat uncomfortable
4..........Very uncomfortable

IF YOU SAID "VERY COMFORTABLE" OR "SOMEWHAT COMFORTABLE" TO THE LAST QUESTION, SKIP TO QUESTION #6.

5. If you might feel uncomfortable working in a primary care setting that offers medication abortion to women as part of their general medical care, then please look at the list below and tell us whether each item is or is not a reason you would feel uncomfortable.

6. Given the necessary training and backup, how interested are you personally in participating in providing medication abortions in a primary care setting at some point in the next year? If you are an administrator or clerical staff member please circle "not applicable."

1..........Very interested
2..........Somewhat interested
3..........Somewhat uninterested
4..........Very uninterested
7..........Not applicable

7. Given the necessary training and backup, how interested are you personally in providing early aspiration abortions in a primary care setting at some point in the next year? If you are an administrator or clerical staff member please circle "not applicable."

1..........Very interested
2..........Somewhat interested
3..........Somewhat uninterested
4..........Very uninterested
7..........Not applicable

8. About what percent of your patients here at this facility are women between the ages of 15 yrs old and 44 yrs old?

__________%

9. Have you ever performed a medication or aspiration abortion?

1..........Yes
2..........No
7..........Not applicable

10. Have you ever assisted in an aspiration abortion procedure?

1..........Yes
2..........No
7..........Not applicable

11. Have you ever assisted in a medication abortion?

1..........Yes
2..........No
7..........Not applicable

12. Have you ever referred a woman for an abortion?

1..........Yes
2..........No
7..........Not applicable

13. The medication abortion pill is fairly new. How much do you know about it?

1..........A lot
2..........Some
3..........A little
4..........Nothing

14. Are you male or female?

0..........Male
1..........Female

15. What is your age?

1..........Less than 20
2..........20 to 29
3..........30 to 39
4..........40 to 49
5..........50 to 59
6..........60 or over

THANK YOU!