1. A health care provider can care for patients in person, by phone, or by video. Our records show that your child got care from the provider named below in the last 6 months.
Name of provider label goes here.
Is that right?
2. Is this the provider you usually see if your child needs a check-up, has a health problem, or gets sick or hurt?
3. How long has your child been going to this provider?
4. In the last 6 months, how many times did your child visit this provider for care?
5. In the last 6 months, were you with your child when they were talking with this provider?
6. Did this provider give you enough information about what was discussed during the visit when you were not there?
7. Is your child able to talk with providers about his or her health care?
8. In the last 6 months, how often did this provider explain things in a way that was easy for your child to understand?
9. In the last 6 months, how often did this provider listen carefully to your child?
10. Did this provider tell you that you needed to do anything to follow up on the care your child got during the visit?
11. Did this provider give you enough information about what you needed to do to follow up on your child's care?
12. In the last 6 months, did you contact this provider's office to get an appointment for your child for an illness, injury, or condition that needed care right away?
13. In the last 6 months, when you contacted this provider's office to get an appointment for care your child needed right away, how often did you get an appointment as soon as your child needed?
14. In the last 6 months, did you make any appointments for a check-up or routine care for your child with this provider?
15. In the last 6 months, when you made an appointment for a check-up or routine care for your child with this provider, how often did you get an appointment as soon as your child needed?
16. In the last 6 months, did you contact this provider's office with a medical question about your child during regular office hours?
17. In the last 6 months, when you contacted this provider's office during regular office hours, how often did you get an answer to your medical question the same day?
18. In the last 6 months, how often did this provider explain things about your child's health in a way that was easy to understand?
19. In the last 6 months, how often did this provider listen carefully to you?
20. In the last 6 months, how often did this provider seem to know the important information about your child's medical history?
21. In the last 6 months, how often did this provider show respect for what you had to say?
22. In the last 6 months, how often did this provider spend enough time with your child?
23. In the last 6 months, did this provider order a blood test, x-ray, or other test for your child?
24. In the last 6 months, when this provider ordered a blood test, x-ray, or other test for your child, how often did someone from this provider's office follow up to give you those results?
25. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?
26. In the last 6 months, how often were clerks and receptionists at this provider's office as helpful as you thought they should be?
27. In the last 6 months, how often did clerks and receptionists at this provider's office treat you with courtesy and respect?
28. In general, how would you rate your child's overall health?
29. In general, how would you rate your child's overall mental or emotional health?
30. What is your child's age?
31. Is your child male or female?
32. Is your child of Hispanic or Latino origin or descent?
33. What is your child's race? Mark one or more.
34. What is your age?
35. Are you male or female?
36. What is the highest grade or level of school that you have completed?
37. How are you related to the child?
38. In the last 6 months, were any of your child's visits with this provider...
39. Did someone help you complete this survey?
40. How did that person help you? Mark one or more.
