Pre-Interview Survey

Attachment V. Pre-Interview Survey

Form Approved

OMB Control No. 0920-XXXX

Expiration Date: XX/XX/XXXX

Pre-Interview Survey – Families with CYSHCN and Autism Spectrum Disorders

1. How many people live in your household?

• How many children?

• How many children with special health care needs do you have?

• Please provide the age of your children with special health care needs (in years): (If you have more than one child with special health care needs, please list the age (in years) of each of your children (e.g., 12, 6)

2. My relationship to my child is (if you have multiple children with special health care needs, select all that apply):

• Mother

• Father

• Foster parent or guardian

• Sister/brother

• Grand parent

• Other ______________________________

3. What language do you prefer to get information when there is an emergency or disaster? ____________________________
   
   
   

4. Where do your children with special health care needs usually get health care? (Check all that apply)

• My child’s primary care provider

• Hospital emergency department

• Specialist doctor or practice (e.g., lung specialist, neurologist)

• A hospital outpatient clinic

• Community health center

• Urgent care/minute clinic

• A school nurse

• Other (please specify): __________________

5. How many total hours per week of home health care support do you receive at present?

• None

• 1-4 hours

• 5-8 hours

• 9-12 hours

• 13-16 hours

• 17-20 hours

• 21-24 hours

• >24 hours
  
  
  

6. How would you describe your ethnicity?

• Non-Hispanic/Latino

• Hispanic/Latino

7. How would you describe your race? Please mark all that apply.

• White

• Black or African American

• American Indian or Alaskan Native

• Asian

• Native Hawaiian or other Pacific Islander

• Other (please specify): ________________________

• Don’t Know

• Refused

8. What is your highest education level? (Please select one choice)

• Some high school

• High school diploma or GED

• Associate’s degree

• Bachelor’s degree

• Education beyond Bachelor’s (Master’s, Doctorate, etc.)

• Other (please specify): ___________________

• Refused

9. What is your household’s combined annual income, meaning the total pre-tax income from all sources earned in the past year?

• Less than $25,000

• $25,000 to less than $35,000

• $35,000 to less than $50,000

• $50,000 to less than $75,000

• $75,000 or More

• Don’t Know

• Refused
  
  

10. Please provide the zip code where you live: _______________________