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
1 2 3 4 5 6 7 8 More than 8
Do you have a child/children ages 12 and older?* must provide value
Yes No
What is your relationship to the child? Parent Grandparent Foster parent Sibling Custodian Guardian Kinship Guardian Other
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) 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Is your child Hispanic?
Yes No
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
Male Female Unknown
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
In what county does your child live most of the time?* must provide value
Adair County Alfalfa County Atoka County Beaver County Beckham County Blaine County Bryan County Caddo County Canadian County Carter County Cherokee County Choctaw County Cimarron County Cleveland County Coal County Comanche County Cotton County Craig County Creek County Custer County Delaware County Dewey County Ellis County Garfield County Garvin County Grady County Grant County Greer County Harmon County Harper County Haskell County Hughes County Jackson County Jefferson County Johnston County Kay County Kingfisher County Kiowa County Latimer County Le Flore County Lincoln County Logan County Love County Major County Marshall County Mayes County McClain County McCurtain County McIntosh County Murray County Muskogee County Noble County Nowata County Okfuskee County Oklahoma County Okmulgee County Osage County Ottawa County Pawnee County Payne County Pittsburg County Pontotoc County Pottawatomie County Pushmataha County Roger Mills County Rogers County Seminole County Sequoyah County Stephens County Texas County Tillman County Tulsa County Wagoner County Washington County Washita County Woods County Woodward County OTHER - OUT OF STATE
In what county does your child receive primary medical care (e.g., from a family doctor or pediatrician)? Adair County Alfalfa County Atoka County Beaver County Beckham County Blaine County Bryan County Caddo County Canadian County Carter County Cherokee County Choctaw County Cimarron County Cleveland County Coal County Comanche County Cotton County Craig County Creek County Custer County Delaware County Dewey County Ellis County Garfield County Garvin County Grady County Grant County Greer County Harmon County Harper County Haskell County Hughes County Jackson County Jefferson County Johnston County Kay County Kingfisher County Kiowa County Latimer County Le Flore County Lincoln County Logan County Love County Major County Marshall County Mayes County McClain County McCurtain County McIntosh County Murray County Muskogee County Noble County Nowata County Okfuskee County Oklahoma County Okmulgee County Osage County Ottawa County Pawnee County Payne County Pittsburg County Pontotoc County Pottawatomie County Pushmataha County Roger Mills County Rogers County Seminole County Sequoyah County Stephens County Texas County Tillman County Tulsa County Wagoner County Washington County Washita County Woods County Woodward County OTHER - OUT OF STATE
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
Do you have concerns about what your child's healthcare coverage/services will be when your child turns 18?
Yes No
Please briefly explain your concerns that you had in mind when you answered YES to the question above:
Do you have a plan for your child's transition to adult healthcare?
Yes No
Please briefly explain your plan you had in mind when you answered YES to the question above:
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
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)
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
OPTIONAL:
If applies, please share your experience with the care coordination activity we asked you about in the question above:
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
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?
Please enter the date of completing this survey.* must provide value
Today 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.