1. Our records show that your child is now in {INSERT HEALTH PLAN NAME}. Is that right?
2. What is the name of your child's health plan?
3. In the last 12 months, did your child have an illness, injury, or condition that needed care right away?
4. In the last 12 months, when your child needed care right away, how often did your child get care as soon as he or she needed?
5. In the last 12 months, did you make any in-person, phone, or video appointments for a check-up or routine care for your child?
6. In the last 12 months, how often did you get an appointment for a check-up or routine care for your child as soon as your child needed?
7. In the last 12 months, not counting the times your child went to an emergency room, how many times did he or she get health care in person, by phone, or by video?
8. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your child's health care in the last 12 months?
9. In the last 12 months, how often was it easy to get the care, tests, or treatment your child needed?
10. A personal doctor is the one your child would talk to if he or she needs a check-up, has a health problem, or gets sick or hurt. Does your child have a personal doctor?
11. In the last 12 months, how many times did your child have an in-person, phone, or video visit with his or her personal doctor?
12. In the last 12 months, how often did your child's personal doctor explain things about your child's health in a way that was easy to understand?
13. In the last 12 months, how often did your child's personal doctor listen carefully to you?
14. In the last 12 months, how often did your child's personal doctor show respect for what you had to say?
15. Is your child able to talk with doctors about his or her health care?
16. In the last 12 months, how often did your child's personal doctor explain things in a way that was easy for your child to understand?
17. In the last 12 months, how often did your child's personal doctor spend enough time with your child?
18. In the last 12 months, did your child's personal doctor talk with you about how your child is feeling, growing, or behaving?
19. Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your child's personal doctor?
20. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 12 months, did you make any appointments for your child with a specialist?
21. In the last 12 months, how often did you get appointments for your child with a specialist as soon as he or she needed?
22. How many specialists has your child talked to in the last 12 months?
23. We want to know your rating of the specialist your child talked to most often in the last 12 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist?
24. In the last 12 months, did you get information or help from customer service at your child's health plan?
25. In the last 12 months, how often did customer service at your child's health plan give you the information or help you needed?
26. In the last 12 months, how often did customer service staff at your child's health plan treat you with courtesy and respect?
27. In the last 12 months, did your child's health plan give you any forms to fill out?
28. In the last 12 months, how often were the forms from your child's health plan easy to fill out?
29. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your child's health plan?
30. In general, how would you rate you child's overall health?
31. In general, how would you rate your child's overall mental or emotional health?
32. What is your child's age?
33. Is your child male or female?
34. Is your child of Hispanic or Latino origin or descent?
35. What is your child's race? Mark one or more.
36. What is your age?
37. Are you male or female?
38. What is the highest grade or level of school that you have completed?
39. How are you related to the child?
40. Did someone help you complete this survey?
41. How did that person help you? Mark one or more.
