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Exit Survey
 
 
You are invited to participate in a survey for a student at Our Lady of the Lake College's School of Nursing. In this survey, you will be asked questions about your child and family. It will take approximately 15 minutes to complete the questionnaire.

Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Amanda Bolton at (225) 252-7254 or by email at the email address specified below.

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.

 
 
 
 
How many people make up your family (including you and your spouse)? Please identify each person's role, age, and sex. (i.e. Katy: child, 4 yrs, female)
   
 
 
 
Please list sources of income for your household. (You do NOT need to include amounts.)
   
 
 
 
This research is specifically targeting medically fragile children and their families. The Department of Health and Hospitals states that a medically fragile child is one who: "require(s) nursing services or therapeutic interventions for all or part of the day due to their complex medical conditions." This may include but is not limited to: tracheostomy care, respiratory care, gastrostomy feedings, therapies, etc. Please specify any children in your home that may be deemed or diagnosed as medically fragile. Briefly discuss their diagnosis or diagnoses, age they received the diagnosis, and the care they require on a daily basis that is specific to their diagnosis (i.e. medications, feedings, and/or oxygen).
   
 
 
 
Does your child participate in one of the following currently?
 
private school
 
public school
 
Pediatric Day Health Care Facility (PDHC)
 
Other
 
 
 
 
Briefly explain why you chose this facility for your child. (Was this the only resource in your community? Financially the best fit for your family?)
   
 
 
 
If your child does NOT attend a Pediatric Day Health Care facility (PDHC), SKIP this question. Which PDHC does your child attend?
 
Pediatria
 
Pediatric Health Choice
 
A Place of Our Own
 
Safe Haven
 
Other
 
 
 
 
Please describe your experience with the facility your child attends. Are you satisfied with the services offered in relation to your child's health care, emotional, educational, etc. needs? Are there improvements or changes you wish to see? If you care for your child at home, what resources would benefit you in order to provide optimal care?
   
 
 
Please rate the following as they relate to your child's needs and/or based on your experience.

Scale: 1-Very Dissatisfied, 2-Dissatisfied 3-Neutral, 4-Satisfied, 5-Very Satisfied
Facility they attend (public school, private school, PDHC, etc)
Community resources (support groups, etc.)
Pediatrician
Hospital (in community or nearest)
 
 
 
Please describe the source(s) for medical insurance for your family, in particular for your child with complex health care needs. (i.e. private insurance, group insurance, Medicaid, etc)