SEARCH Quality of Care Survey (Feb 2014)

Form Approved
OMB No. 0920-0904
Exp. Date 11/30/2014

Patient ID
Number
Site

Sub-site

Sequential ID

SEARCH STUDY
QUALITY OF CARE SURVEY
Parent/Guardian Version
This survey is to be filled out by the Parent/legal Guardian of the child age less than 18 years old
who has diabetes.

Public reporting burden of this collection of information is estimated to average 13 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer; 1600 Clifton
Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0904).
SEARCH 3 Cohort Study - Quality of Care Survey – Parent Version – revised 10-26-11

This survey asks questions about your experiences with health care and
how you and your child take care of diabetes on your own. There are no
right or wrong answers and all of the information you provide will be kept
confidential. Your answers will help us learn more about the quality of
health care patients and their families receive for diabetes.
HEALTH INSURANCE
1.

Has your child had health insurance continuously during the past 12 months?

 Yes 2 No

1

If no, for how many months was your child not covered by health
insurance? _______months.

YOUR CHILD’S HEALTH CARE
IN THE LAST 12 MONTHS
The next questions ask about your child’s health care in general. Do not include care
your child got when he or she stayed overnight in a hospital. Do not include the times
your child went for dental care visits.

2.

In the last 12 months, how much of a problem, if any, was it to get the care, tests,
or treatment you or a doctor believed necessary?



3

1
2

3.

A big problem
A small problem
Not a problem

In the last 12 months, has there been a time when you thought your child should
get care but did not receive it?
1
 Yes
2
 No

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4.

How much of a problem is the cost of your child’s health care for you (including
paying for health insurance premiums and co-payments for doctor’s office visits,
medications, and medical supplies)?



3

1
2

A big problem
A small problem
Not a problem

PRESCRIPTION MEDICATIONS

5.

In the last 12 months, how much of a problem, if any, was it to get your child’s
prescription medicine and medical supplies?



3

1
2

A big problem
A small problem
Not a problem

EXPERIENCES WITH CARE
__________________________________________________________________________
6.

In the last 12 months, did your child’s doctors or other health providers talk with
you about how your child is feeling, growing or behaving?


2

1

7.

Do your child’s doctors or other health providers understand how your child’s
medical, behavioral or other health conditions affect your child’s day-to-day life?




1
2

8.

Yes
No

Yes
No

Do your child’s doctors or other health providers understand how your child’s
medical, behavioral or other health conditions affect your family’s day-to-day life?


2

1

Yes
No

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9.

In the last 12 months, how often did your child’s doctors or health providers:
Never Sometimes Usually Always

10.




2


2

3

4




3



3



3



4





4



4



4





Yes
No  (If No, go to Question 14)

Never
Sometimes
Usually
Always

In the last 12 months, how often did you have your questions answered by your
child’s doctors or other health providers?


2

3

4

1

13.

3

In the last 12 months, how often did your child’s doctors or other health providers
make it easy for you to discuss your questions or concerns?
1

12.



In the last 12 months, did you have any questions or concerns about your child’s
health or health care?
1

11.

2

1



9d. Spend enough time with your child?

2

1



9c. Show respect for what you had to say?

2

1



9b. Explain things in a way you could
understand?

2

1



9a. Listen carefully to you?

Never
Sometimes
Usually
Always

In the last 12 months, how often did you get the specific information you needed
from your child’s doctors or other health providers?



3

4

1
2

Never
Sometimes
Usually
Always

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14.

In the last 12 months, how often did you have a hard time speaking with or
understanding your child’s doctors or other health providers because they spoke
different languages?



3

4

1
2

15.

Never
Sometimes
Usually
Always

An interpreter is someone who repeats or signs what one person says in a
language used by another person.
In the last 12 months, did you need an interpreter to help you speak with your
child’s doctors or other health providers?




1
2

16.

Yes
No  (If No, go to Question 17)

In the last 12 months, when you needed an interpreter to help you speak with your
child’s doctors or other health providers, how often did you get one?



3

4

1
2

Never
Sometimes
Usually
Always

HEALTH CARE DECISIONS
___________________________________________________________________________
We want to know how you, your child’s doctors and other health providers make
decisions about your child’s health care.
17. In the last 12 months, were any decisions made about your child’s health care?




1
2

Yes
No  (If No, go to Question 19)

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18. When decisions were made in the last 12 months, how often did your child’s
doctors or other health providers:
Never Sometimes Usually Always

2

1



18d. Involve you as much as you wanted?

2

1



18c. Ask you to tell them what choices you
prefer?

2

1



18b. Discuss with you the good and bad things
about each of the different choices for
your child’s health care?

2

1



18a. Offer you choices about your child’s health
care?



3



3



3



3



4





4



4



4





YOUR CHILD’S PERSONAL DOCTOR OR NURSE
19.

A personal doctor or nurse is the health provider who knows your child best. This
can be a general doctor, a specialist doctor, a nurse practitioner, or a physician
assistant.
Do you have one person you think of as your child’s personal doctor or nurse? If
your child has more than one personal doctor or nurse, choose the person your
child sees most often.

 Yes
 No 

1
2

20.

(If No, go to Question 21)

Using any number from 0 to 10 where 0 is the worst personal doctor or nurse
possible and 10 is the best personal doctor or nurse possible, what number would
you use to rate your child’s personal doctor or nurse?

0

1

2

3

4

5

6

Worst
personal
doctor or
nurse
possible

SEARCH 3 Cohort Study - Quality of Care Survey – Parent Version – revised 10-26-11

7

8

9

10
Best
personal
doctor or
nurse
possible

6

21. Using any number from 0 to 10 where 0 is the worst health care possible and 10 is
the best health care possible, what number would you use to rate all your child’s
health care in the last 12 months?

0

1

2

3

4

5

6

7

8

9

Worst
health
care
possible

22.

10
Best
health
care
possible

In general, how would you rate your child’s overall health now?

 Excellent
 Very Good
3
 Good
4
 Fair
5
 Poor
1
2

Transition from Pediatric to Adult Care
___________________________________________________________
The next questions are about preparing for your child’s health care needs as he/she
becomes an adult.
23. Is your child 12 yrs. of age or older?
 Yes
 No (skip to question 32)
24. Which of the following best describes your child’s current diabetes provider?
 He/She is a pediatric provider, who treats mainly children
 He/She is an adult provider who treats mainly adults, except for a few children –
(skip to question 32)

 He/She is an adult and pediatric provider, who treats patients of all ages (skip to question 32)

 Not sure how to describe my child’s current diabetes provider

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25. Have they talked with you about having your child eventually see doctors or other
health care providers who treat adults?
 Yes (skip to question 27)
 No
 Not sure
26. Would a discussion about doctors who treat adults have been helpful to you?
 Yes
 No
 Not sure
27. Have your doctors or other health care providers talked with you about your child’s
health care needs as your child becomes an adult?
 Yes (skip to question 29)
 No
 Not sure
28. Would a discussion about your child’s health care needs have been helpful?
 Yes
 No
 Not sure
29. Eligibility for health insurance often changes as children reach adulthood. Has
anyone discussed with you how to obtain or keep some type of health insurance
coverage for your child as he/she becomes an adult?
 Yes (skip to question 31)
 No
 Not sure

30. Would a discussion about health insurance have been helpful to you?
 Yes
 No
 Not sure

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31. How often do your doctors or other health care providers encourage your child to
take responsibility for his/her health care needs, such as taking medication,
checking blood sugars, understanding his/her health, or following medical advice?
 Never
 Sometimes
 Usually
 Always
 Don’t know

HEALTH CARE FOR DIABETES

32.

For the next set of items, please indicate if your doctor or other health provider
has talked to you/your child, about the following:
a. What to do for low blood sugar?
b. What to do for high blood sugar?
c. Appropriate physical activity for your
child?
d. Dietary guidelines for diabetes?
e. What a target blood sugar is for your
child?
f. How to adjust your child’s insulin or
diabetes medication when he/she is
sick?
g. Psychological issues your child and
your family may face with regard to
having diabetes?
h. Who you can go to for general
information about diabetes?

33.

 Yes
1
 Yes
1
 Yes
1
 Yes
1
 Yes
1

 No
2
 No
2
 No
2
 No
2
 No
2

 Yes

2

 Yes

2

 Yes

2

1

1

1

 No

 Unsure
 Unsure
3
 Unsure
3
 Unsure
3
 Unsure
3
 Unsure/
3
3

no diabetes
medications
prescribed

 No

3

 Unsure

 No

3

 Unsure

A test for hemoglobin A1C ("A one C") measures the average level of blood sugar
over the past three months. About how many times in the past 12 months has a
doctor or other health provider checked your child’s hemoglobin A1C?
1
 None
2
 Once
3
 Twice
4 Three or more times
5 Don’t know/ Not sure

SEARCH 3 Cohort Study - Quality of Care Survey – Parent Version – revised 10-26-11

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34.

What A1C do you want your child to have?
______ (write in number)

 Don’t know/ Not sure
35.

During the past 12 months, how often has your child’s blood pressure been
checked during visits to your doctor’s office?

 Every visit
2 Most visits
3 At least once
4 Never
5 Don’t know/ Not sure
1

36.

When was the last time your child had an eye exam by an eye specialist in which
his/her pupils were dilated (drops in his/her eyes that make eyes temporarily
sensitive to bright light) or a diabetes eye exam?

 In the past year
2 More than a year but less than 2 years
3 2 – 5 years
4 More than 5 years
5 Never
6 Don’t know/Not sure
1

37.

When was the last time your child had a urine test at the doctor’s office to check
on his/her kidney functioning?

 In the past year
2 More than a year but less than 2 years
3 2 – 5 years
4 More than 5 years
5 Never
6 Don’t know/Not sure
1

SEARCH 3 Cohort Study - Quality of Care Survey – Parent Version – revised 10-26-11

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38.

When was the last time your doctor took a sample of your child’s blood to test for
cholesterol or the amount of fat in your child’s blood?

 In the past year
2 More than a year but less than 2 years
3 2 – 5 years
4 More than 5 years
5 Never
6 Don’t know/Not sure
1

39.

When was the last time your child took off his/her shoes and socks in your
doctor’s office to have your child’s feet examined to check the feeling in his/her
feet?

 In the past year
2 More than a year but less than 2 years
3 2 – 5 years
4 More than 5 years
5 Never
6 Don’t know/Not sure
1

DIABETES SELF-CARE
The following questions ask about what you and your family usually do to take care of
your child’s diabetes. There are no right or wrong answers. Please think about the past
3 months and select the answer that comes closest to what your child has done.

40.

Does your child wear or carry anything that identifies him/her as having diabetes,
like a card or bracelet?

 Wears necklace, bracelet or charm
2 Carries billfold identification card only
3 Has identification but does not wear or carry it
4 Does not have identification about diabetes
1

SEARCH 3 Cohort Study - Quality of Care Survey – Parent Version – revised 10-26-11

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HYPOGLYCEMIA

Please think about what you or your child usually did about low blood sugar reactions
in the past 3 months.

41.

Does your child keep something with her/him to eat in case his/her blood sugar
gets too low?

 Yes
2 No
3 Does not have low blood sugars/no prescribed diabetes medications  (Go to
1

Question 44)

42.

If you/your child think he/she has a low blood sugar, how often do you or your
child test before treating?

 Always
2 More than half the time
3 Half the time
4 Less than half the time
5 Never
6 Does not have low blood sugars/no prescribed diabetes medications
1

43.

If you/your child think he/she has a low blood sugar, does he/she eat until feeling
better?
1

 Yes 

43a. If Yes, do you give or does your child take extra insulin for the
food eaten while feeling low?
1 No
2 Yes - Always
3 Yes – If more that 15 grams of carbohydrates eaten
4 Yes – If more than 30 grams of carbohydrates eaten

 No
3 Does not have low blood sugars/no prescribed diabetes medications
2

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EATING

44.

Children with diabetes receive different dietary recommendations, depending on
their own individual needs. Please indicate below which of the dietary
recommendations you have received for your child from health care providers,
and how frequently each method is currently used.

Dietary Recommendations
keep track of calories
count carbohydrates
choose low glycemic index foods
use dietary exchanges
keep track of fat grams
limit sweets
limit high fat foods
drink more milk
eat more fruits and vegetables
eat more fiber and whole grains

45.

Have you ever received
this recommendation
for your child?
Yes No Don’t know

How frequently do you or
your child currently use this
method?
Often Sometimes Never

Have you or your child been taught about how to adjust your child’s insulin
depending on how much or what kinds of food your child eats?

 Yes  45a.

1

If YES, how often do you or your child adjust insulin based on
what he/she has eaten?
1 Often

 Sometimes
3 Never
2

 No
3 Does not apply - insulin not prescribed for child
2

SEARCH 3 Cohort Study - Quality of Care Survey – Parent Version – revised 10-26-11

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BLOOD SUGAR TESTING

The following questions have to do with your child’s habits when it comes to testing
blood sugar. Please think about the past 3 months and choose the answer that is
closest to what you or your child has done.

46.

In the past 3 months, how often have you or your child tested his/her blood
sugar?

 6 or more times daily
2 4 or 5 times daily
3 2 or 3 times daily
4 At least once daily
5 Does not test, or tests less than once a day
6 Don’t know
1

47.

How often has your child’s diabetes care provider suggested that your child’s
blood sugar be tested?

 6 or more times daily
2 At least 4 or 5 times daily
3 At least 2 or 3 times daily
4 At least once daily
5 Don’t know
1

Thank you for completing this survey. We appreciate your participation
in this important study!

FOR STUDY USE ONLY
Date
Completed
Date
Reviewed
Date
Entered

Month

Month

Month

Day

Day

Day

Year

Year

Year

Completer
Code
Reviewer
Code
Data Entry
Code

SEARCH 3 Cohort Study - Quality of Care Survey – Parent Version – revised 10-26-11

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