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The Children with Special Health Care Needs Program staff help families get the information they need to care for their child with special needs. The Program workers help families get insurance, find specialty doctors, and get assistance for health and other community services and supports. Some local Programs may give financial help to children through their Physically Handicapped Children (PHC)'s Program. This program may or may not be available where you live. We ask you to complete a survey on your experiences. For this survey, think of the PHC Program as part of a local Program. We value your feedback about these programs. The information will be used to improve how we serve families of 1. What county or municipality do you live in? 2. How did you hear about the Children with Special Health Care Needs Program? 3. How many times have you had contact with the Program in the past year? Program Family Satisfaction Survey * 6 * State and Local Health Department printed materials n m l k j Internet/Facebook/Twitter n m l k j TV/Radio/Newspaper n m l k j Doctor/hospital n m l k j Community service provider(such as School,Early Intervention) n m l k j Family, friend or parent organization n m l k j Other please specify n m l k j None n m l k j 1 n m l k j 23 n m l k j 4 or more n m l k j ---PAGE BREAK--- 4. Families often need help with finding and getting medical services and supports for their child with special needs. The following list describes the kinds of help the Program may provide. For each type of help listed below, tell us whether you needed this help or not and whether you got the help you needed. Not Needed Needed and Got Help Needed but Didn't Get Help a. Getting information about health insurance (such as Medicaid, Child Health Plus, Family Health Plus etc.) g f e d c g f e d c g f e d c b. Paying for medical expenses not covered by health insurance g f e d c g f e d c g f e d c c. Finding a medical specialist g f e d c g f e d c g f e d c d. Finding a dentist g f e d c g f e d c g f e d c e. Finding a dental specialist (orthodontist, oral surgeon) g f e d c g f e d c g f e d c f. Getting information about other resources in your community (such as, parent organizations, support groups, respite, transportation, translation services etc.) g f e d c g f e d c g f e d c h. Getting connected with resources in the community (also known as referrals) g f e d c g f e d c g f e d c i. Getting help with filling out applications (such as health insurance, PHCP, SSI) g f e d c g f e d c g f e d c ---PAGE BREAK--- 5. How easy is it to get information and help from the Program staff when needed (hours of operation, availability to answer questions, etc.)? 6. How satisfied are you with the help given by the Program staff to meet your needs? 7. How would you rate the Program? 8. Please tell us how the Program was helpful or not helpful. 9. What suggestions do you have to improve our program? 10. How old is your child with special health care needs? If you have more than one child with special needs, check a box for the age of the first child, and tell us the ages of the other children in the box labelled "Other". * * * Excellent Good Fair Poor overall rating n m l k j n m l k j n m l k j n m l k j 5 5 6 6 5 5 6 6 Always easy n m l k j Sometimes easy n m l k j Never easy n m l k j Very satisfied n m l k j Satisfied n m l k j Somewhat satisfied n m l k j Not satisfied n m l k j Under 1 year g f e d c 13 years g f e d c 35 years g f e d c 617 years g f e d c 18 21 years g f e d c Other (please specify) ---PAGE BREAK--- 11. What race would you consider your child(ren) with special health care needs? May choose more than one. 12. Have you been told by a doctor or healthcare provider that your child(ren) with special health care needs has any of these health conditions? (check all that apply) If you received a print copy of the survey, you may complete the survey online using the link below: * Hispanic/Latino g f e d c American Indian g f e d c White g f e d c Asian g f e d c African American/Black g f e d c Hawaiian or Pacific Islander g f e d c Other (please specify) g f e d c ADHD g f e d c Asthma g f e d c Blood problems g f e d c Cancer g f e d c Diabetes g f e d c Cerebral palsy g f e d c Cystic fibrosis g f e d c Dental problems g f e d c Developmental delay g f e d c Emotional/Behavior/Mental problems g f e d c Heart problems g f e d c Hearing problems g f e d c Inherited metabolic disease g f e d c Prematurity g f e d c Seizures g f e d c Spina bifida g f e d c Thyroid problem g f e d c Other (please specify)