8 = DON’T KNOW (GO TO 17 INTRO) 9 = REFUSED (GO TO 17 INTRO) manage your child’s care or treatment from different doctors or care providers? 3C. Another provider from a different office/clinic A care coordinator who isn’t part of [FILL 1A’s] office staff A social worker who isn’t part of [1A’s] office staff A care or case manager who isn’t part of [1A’s] office staff Someone else who isn’t part of [1A’s] office staff Who was it that helped you? If more than one person helped you, we want to know the person who helped you most often in the last 12 months. ALL GO TO 5A 4. 1. Your child’s main provider 2. Another doctor or nurse in the main provider’s office 3. A clerk or receptionist in the main provider’s office 4. A care coordinator in the main provider’s office 5. A social worker in the main provider’s office 6. A care manager or case manager in the main provider’s office 7. Someone else in the main provider’s office 8 = DON’T KNOW 9 = REFUSED Who in the main provider’s office helped you? If more than one person helped you, we want to know the person who helped you most often in the last 12 months. 5a. 1 = Yes, definitely 2 = Yes, somewhat 3 = No 8 = DON’T KNOW 9 = REFUSED In the last 12 months, did the person who helped you with managing your child’s care know the important information about your child’s health and care needs? Would you say: 5b. 1 = Yes, definitely 2 = Yes, somewhat 3 = No 8 = DON’T KNOW In the last 12 months, did the person who helped you with managing your child’s care seem informed and up-to-date about the
4. Not at all well 17. 0=NO (GO TO 22) 1=YES 8 = DON’T KNOW 9 = REFUSED Do you speak a language other than English at home? 18. 1. SPANISH 2. SOME OTHER LANGUAGE 8 = DON’T KNOW 9 = REFUSED What is the language you speak at home? 19. 1. ENGLISH (GO TO #22) 2. ANOTHER LANGUAGE 8 = DON’T KNOW 9 = REFUSED Do you prefer to talk with your child’s doctors and care providers in English or in another language? 20. 1. No visits (GO TO #22) 2. Some visits 3. Most visits 4. All visits 8 = DON’T KNOW 9 = REFUSED A medical interpreter is a professional who helps you talk with doctors and other providers who do not speak your language. The interpreter can do this over the phone or in-person. In the last 12 months, how often did you need an interpreter during a visit to the main provider? 21. 1. Never 2. Sometimes 3. Usually 4. Always 8 = DON’T KNOW 9 = REFUSED When you needed a professional interpreter during a visit to the main provider, how often was an interpreter available? 22. 1. YES, HISPANIC OR LATINO 2. NO, NOT HISPANIC OR LATINO 8 = DON’T KNOW 9 = REFUSED Is this child of Hispanic or Latino origin or descent? 23. 1. White 2. Black or African American 3. Asian 4. Native Hawaiian or Other Pacific Islander 5. American Indian or Alaska Native 6. Other 8 = DON’T KNOW 9 = REFUSED What is this child’s race? Please choose one or more from this list: 24. 18 TO 24 What is your age?
25 TO 34 35 TO 44 45 TO 54 55 TO 64 65 TO 74 75 OR OLDER 8 = DON’T KNOW 9 = REFUSED 25. 1. MALE 2. FEMALE 8 = DON’T KNOW 9 = REFUSED I’m required to ask, are you male or female? 26. 1. YES, HISPANIC OR LATINO 2. NO, NOT HISPANIC OR LATINO 8 = DON’T KNOW 9 = REFUSED Are you of Hispanic or Latino origin or descent? 27. 1. White 2. Black or African American 3. Asian 4. Native Hawaiian or Other Pacific Islander 5. American Indian or Alaska Native 6. Other 8 = DON’T KNOW 9 = REFUSED What is your race? Please choose one or more from this list. 28. 1. 8th grade or less 2. Some high school, but did not graduate 3. High school graduate or GED 4. Some college or 2-year degree 5. 4-year college graduate 6. More than 4-year college degree 8 = DON’T KNOW 9 = REFUSED What is the highest grade or level of school that you have completed? THANKS EMPTY That’s the end of the survey. Thank you very much for participating. Do you have any questions for me before we end the call?