This resource contains a survey tool used to assess barriers to contraception access identified by providers and staff working at family medicine residency health centers. There are two Word document versions with provider vs. staff specific questions. The survey was designed to provide internal consistency by asking about barriers in two different ways (Likert scale and ranking questions). Additionally, the survey assessed study participants' knowledge of contraception. This survey tool was used in data collection for a PRiMER manuscript describing clinician and staff perceptions of barriers to providing contraception in primary care.