Healthcare Transition to Adulthood Survey

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Thank you for your willingness to take the Sooner SUCCESS Healthcare Transition Survey!

This is a research project. Healthcare Transition occurs when your child grows up to become an adult (usually around 18 years of age) and needs to receive adult healthcare services. There are two important parts of this transition. Your child may need to change his/her healthcare provider to a clinician that can take care of adults. In addition, the transition may also help your child gain the skills necessary for making his/her own healthcare decisions.

Purpose: To help improve the healthcare transition process your child may need to go through.

Please take a few minutes to complete this survey. If you have more than one child, please complete a separate survey for each child. The survey is completely voluntary. Your responses will remain confidential. Your input is important to us. Thank you for your time and sharing your thoughts!

How many people live in your home?

* must provide value

Do you have a child/children ages 12 and older?

* must provide value

Yes No

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What is your relationship to the child?

How did you hear about this survey? (e.g., doctor, DHS, service providers)

Oklahoma Family Network (OFN)

SoonerSUCCESS

Social Media (e.g., Facebook or Twitter)

Community Service Providers (e.g., health department)

Other (use text box below)

How did you hear about this survey - enter other source of information:

What is the age of your child? (e.g., 13)

Is your child Hispanic?

Yes No

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What is the race of your child?

White/Caucasian

Black/African American

American Indian/Native American/Alaskan

Asian

Hawaiian/Pacific Islander

Multiple

Other

What is your child's gender?

* must provide value

Does your family or your child participate in:

SNAP (Food Assistance Program)

School meals (e.g., breakfast and lunch)

Please select if the food program your child participates in is:

Free Reduced price

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In what county does your child live most of the time?

* must provide value

In what county does your child receive primary medical care (e.g., from a family doctor or pediatrician)?

What types of specialists is your child currently seeing (e.g., for Congenital Heart Disease, autism)? Indicate if you don't know.

* must provide value

Adolescent Medicine

Cardiology

Cleft Lip and Palate

Critical Care

Dental Care

Dermatology

Developmental and Behavioral Pediatrics

Diabetes/Endocrinology

Emergency Medicine

Gastroenterology & Nutrition

General and Community Pediatrics

Genetics

Hematology/Oncology

Infectious Disease

Mental Health

Neonatal/Perinatal Medicine

Nephrology

Neurology

Neurosurgery

Ophthalmology

Orthopedics

Otolaryngology (Ear, Nose and Throat)

Pulmonology

Rheumatology

Surgery

Urology

Other

Don't know

What type of primary care clinician does your child have?

Pediatrician

Family Doctor

Physician Assistant (PA)

Family Nurse Practitioner (NP)

Pediatric Nurse Practitioner (NP)

No Primary Care Doctor

Has your provider discussed your child's healthcare transition with you?

Yes No

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Do you have concerns about what your child's healthcare coverage/services will be when your child turns 18?

Yes No

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Please briefly explain your concerns that you had in mind when you answered YES to the question above:

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Do you have a plan for your child's transition to adult healthcare?

Yes No

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Please briefly explain your plan you had in mind when you answered YES to the question above:

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If your child is 18 or older, do you have a guardianship of your child ? (Guardianship is a right to make legal decisions, to have access to healthcare information, to consent on behalf of your child especially for release of medical information.)

Yes No Does Not Apply

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What type of guardianship is it?

General guardianship (full authority to make a child's health care decisions)

Limited guardianship (limited powers over a child's health care decisions)

Special guardianship (powers to make child's emergency health care decisions, only)

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If your child is 18 or older and had a pediatric healthcare provider, did the provider successfully coordinate the healthcare transition for your child?

Yes No Does Not Apply

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OPTIONAL:
If applies, please share your experience with the care coordination activity we asked you about in the question above:

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What type of PRIMARY insurance does your child have currently? (Please check that all apply.)

* must provide value

SoonerCare

Aetna

BlueCross Blue Shield

Tricare

No insurance

Other (describe in text box below)

If you have another type of primary insurance, please describe it:

What type of SECONDARY insurance does your child have currently? (Please check that all apply.)

SoonerCare

Aetna

BlueCross Blue Shield

Tricare

No insurance

Other (use text box below)

If you have another type of secondary insurance, please describe it:

How satisfied are you with you child's current medical coverage or insurance?

Very satisfied

Satisfied

Somewhat satisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

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What do you think your child's health insurance coverage will be after he/she turns 18?

SoonerCare Aetna BlueCross Blue Shield Tricare No insurance Other (use text box below)

What OTHER insurance will your child have?

Has your child received any help or services to make transitions to:

Adult Healthcare Work Independent Living

Please explain briefly what services or help has your child received to transition to adulthood?

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Please enter the date of completing this survey.

* must provide value

M-D-Y

Thank you for taking the time to complete this survey!
If you want to know more about this survey or the services offered by Sooner SUCCESS, please contact us at soonersuccess@ouhsc.edu or call us at 877-441-0434. You can also visit our website at http://soonersuccess.ouhsc.edu.

You have selected an option that triggers this survey to end right now. To save your responses and end the survey, click the button below to do so. If you have selected the wrong option by accident and do not wish to leave the survey, you may click the other button below to continue, which will also remove the value of the option you just selected to allow you to enter it again and continue the survey.

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This value is admissible, but you may wish to verify.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

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/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

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