Healthcare Transition to Adulthood Survey

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!

Yes No

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Oklahoma Family Network (OFN)

SoonerSUCCESS

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

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

Other (use text box below)

Yes No

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White/Caucasian

Black/African American

American Indian/Native American/Alaskan

Asian

Hawaiian/Pacific Islander

Multiple

Other

SNAP (Food Assistance Program)

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

Free Reduced price

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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

Pediatrician

Family Doctor

Physician Assistant (PA)

Family Nurse Practitioner (NP)

Pediatric Nurse Practitioner (NP)

No Primary Care Doctor

Yes No

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Yes No

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Yes No

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Yes No Does Not Apply

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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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Yes No Does Not Apply

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SoonerCare

Aetna

BlueCross Blue Shield

Tricare

No insurance

Other (describe in text box below)

SoonerCare

Aetna

BlueCross Blue Shield

Tricare

No insurance

Other (use text box below)

Very satisfied

Satisfied

Somewhat satisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

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

Adult Healthcare Work Independent Living

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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.

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

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

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

Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((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}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

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/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

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/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])$?)\s*(?:[.-]\s*)?([2-9]\d{2})\s*(?:[.-]\s*)?(\d{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

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/^[0-5]\d:[0-5]\d$/

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