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MAX Survey - Exceptional Family Member Program (EFMP) Pilot Program Evaluation at Travis Air Force Base Survey
Exceptional Family Member Program
(EFMP) Pilot Program Evaluation at
Travis Air Force Base Survey
OMB CONTROL NUMBER: 0720-EFMP
OMB EXPIRATION DATE: XX/XX/XXXX
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0720-EFMP, is estimated to average
20 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding the burden estimate or burden reduction suggestions to
the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other
provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number.
Thank you for participating in the evaluation of an Exceptional Family Member Program (EFMP)
pilot program at Travis Air Force Base. A portion of the evaluation includes capturing information
from EFMP families to examine the impact of the program on the health and health care of EFMPenrolled dependents in your family. Please take time to complete this voluntary survey below. Your
response will be kept confidential. Your care will not be affected by participation.
There are 60 questions in this survey.
Background
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1
Please select your relation to the EFMP-enrolled
dependent(s) in your family. Select all that apply.
Are you the:
Check all that apply
Please choose all that apply:
Sponsor
Primary caregiver (by primary caregiver we mean the parent or guardian living in the
household who knows about the health and health care of the dependent)
EFMP-enrolled dependent
Other, please explain. (Do not include any personal identifiable information.)
Other:
2
How many permanent changes of station (PCS’s) has
your family experienced since enrolling in EFMP?
Choose one of the following answers
Please choose only one of the following:
None, enrolled in EFMP at Travis AFB
1
2-3
4 or more
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3
How long has your family been stationed at Travis
AFB?
Please write your answer(s) here:
Months
Years
CareStarter Materials and Resources
4
Did your family receive materials from CareStarter
prior to your PCS to Travis AFB?
Please choose only one of the following:
Yes
No
I don't know
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5
Did receiving these materials prior to your PCS to
Travis AFB enable your family to:
Select all that apply.
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G02Q04]' (Did your family receive materials from
CareStarter prior to your PCS to Travis AFB? )
Please choose all that apply:
Plan for locating care before you arrived at Travis AFB
Identify available resources/care prior to your PCS to Travis AFB
Establish appointments with providers prior to your PCS to Travis AFB
6
What materials do/did your family use from
CareStarter? Select all that apply.
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G02Q04]' (Did your family receive materials from
CareStarter prior to your PCS to Travis AFB? )
Please choose all that apply:
CareMap
CareStarter App
CareStarter Website
Do/did not use CareStarter materials
Other. Please explain. (Do not include any personal identifiable information.)
Other:
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7 How easy or difficult was it to use the materials
from CareStarter?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G02Q04]' (Did your family receive materials from
CareStarter prior to your PCS to Travis AFB? )
Please choose only one of the following:
Very difficult
Difficult
Neither easy nor difficult
Easy
Very easy
8
How useful were the materials provided by
CareStarter?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G02Q04]' (Did your family receive materials from
CareStarter prior to your PCS to Travis AFB? )
Please choose only one of the following:
Not at all useful
A little useful
Useful
Very useful
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9
Please identify any medical or non-medical resources
from the CareStarter resource list that your family
has used to support the care of your EFMP-enrolled
family member(s). Select all that apply.
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G02Q04]' (Did your family receive materials from
CareStarter prior to your PCS to Travis AFB? )
Please choose all that apply:
Medical Resources
Therapy Resources
Educational Resources
Family Support Resources
Nutritional Resources
Recreational Resources
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10
Please rate the usefulness of the resource list from
CareStarter for identifying and locating each of the
resources for your EFMP-enrolled family members. If
you did not use a resource from the CareStarter
resource list, select "N/A, did not use this resource."
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G02Q04]' (Did your family receive materials from
CareStarter prior to your PCS to Travis AFB? )
Please choose the appropriate response for each item:
Not at all
useful
A little
useful
Useful
Very
useful
N/A, did
not use
this
resource.
Medical Resources
Therapy Resources
Educational Resources
Family Support
Resources
Nutritional Resources
Recreational Resources
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11
Is/are your EFMP-enrolled family members still using
each of the following resources? If you never used
the resource, select "N/A."
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G02Q04]' (Did your family receive materials from
CareStarter prior to your PCS to Travis AFB? )
Please choose the appropriate response for each item:
Yes, we are still
using this
resource.
No, we are no
longer using this
resource.
N/A, we never
used this
resource.
Medical Resources
Therapy Resources
Educational Resources
Family Support
Resources
Nutritional Resources
Recreational
Resources
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12
What was most helpful/useful about the CareStarter
program for your family?
Do not include any personal identifiable information.
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G02Q04]' (Did your family receive materials from
CareStarter prior to your PCS to Travis AFB? )
Please write your answer here:
13
Overall, how would you rate your satisfaction with
CareStarter?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G02Q04]' (Did your family receive materials from
CareStarter prior to your PCS to Travis AFB? )
Please choose only one of the following:
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
EFMP-Enrolled Dependents
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14 Did/do you have EFMP-enrolled pediatric
dependent(s) are in your family unit?
Please choose only one of the following:
Yes
No
15
How many EFMP-enrolled pediatric dependents are in
your family unit?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G03Q16]' (Did/do you have EFMP-enrolled pediatric
dependent(s) are in your family unit?)
Please write your answer here:
16
Did/do you have EFMP-enrolled adult dependent(s)
are in your family unit?
Please choose only one of the following:
Yes
No
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17
How many EFMP-enrolled adult dependents are in
your family unit?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G01Q51]' (Did/do you have EFMP-enrolled adult
dependent(s) are in your family unit? )
Please write your answer here:
Healthcare Profiles
If you have more than one EFMP-enrolled dependent, please complete the following section
based on the dependent who has the most complex care needs.
18
If you have more than one EFMP-enrolled dependent,
please complete the following sections based on the
dependent who has the most complex care needs. Is
this a pediatric or adult dependent?
Please choose only one of the following:
Pediatric dependent
Adult dependent
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19 In general, how would you rate the health care
received for your EFMP-enrolled dependent(s)?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G03Q16]' (Did/do you have EFMP-enrolled pediatric
dependent(s) are in your family unit?)
Please choose only one of the following:
Excellent
Very good
Good
Fair
Poor
Not sure
Prefer not to answer
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20
Which health plan did you use for most of your EFMPenrolled dependent's health care in the last 12
months?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G03Q16]' (Did/do you have EFMP-enrolled pediatric
dependent(s) are in your family unit?)
Please choose only one of the following:
TRICARE Prime (including TRICARE Prime Remote and TRICARE Overseas)
TRICARE Select (CHAMPUS)
TRICARE Reserve Select
TRICARE Retired Reserve
TRICARE Young Adult Prime
TRICARE Young Adult Select
Uniformed Services Family Health Plan (USFHP)
Continued Health Care Benefit Program (CHCBP) (a COBRA-like premium-based
health care program)
Federal Employees Health Benefit Program (FEHBP)
Medicaid
A government program for children (for example, CHIP)
A civilian HMO (for example, Kaiser Permanente)
Other civilian health insurance (for example, Blue Cross)
Government health insurance from a country other than the US
My pediatric dependent was not covered by any health plan in the last 12 months
Not sure
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21
In the last 12 months, how many months in a row
was/were your EFMP-enrolled dependent in this
health plan?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G03Q16]' (Did/do you have EFMP-enrolled pediatric
dependent(s) are in your family unit?)
Please choose only one of the following:
Less than 2 months
2-6 months
7-12 months
Not enrolled in a health plan in the last 12 months
22
Is your EFMP-enrolled dependent registered in The
Extended Care Health Option (ECHO)?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G03Q16]' (Did/do you have EFMP-enrolled pediatric
dependent(s) are in your family unit?)
Please choose only one of the following:
Yes
No
I don't know
Other Resources
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23
Which of the following resources did you use to locate
and establish care for your EFMP-enrolled dependent
at Travis AFB? Select all that apply.
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G03Q16]' (Did/do you have EFMP-enrolled pediatric
dependent(s) are in your family unit?)
Please choose all that apply:
Primary Care at your previous installation
Primary Care at Travis
ECHO Case Manager
TRICARE or HealthNet provider directory
Travis EFMP Special Needs Coordinator
Materials from CareStarter (e.g., CareMap, CareStarter App)
None
Other. Please describe. (Do not include any personal identifiable information. )
Other:
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24 Please rate your level of confidence with using the
following resources at your prior base (pre-PCS):
Please choose the appropriate response for each item:
N/A; I
do not
use
No
Little
Some
Highly
this
confidenceconfidenceconfidenceConfident confident resource
Primary Care at your
previous installation
Primary Care at Travis
AFB
Echo Case Manager
TRICARE or HealthNet
provider directory
Materials from
CareStarter (e.g.,
CareMap, CareStarter
App)
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25 Please rate your current level of confidence with
using the following resources:
Please choose the appropriate response for each item:
N/A; I
do not
use
No
Little
Some
Highly
this
confidenceconfidenceconfidenceConfident confident resource
Primary Care at your
previous installation
Primary Care at Travis
AFB
Echo Case Manager
TRICARE or HealthNet
provider directory
Materials from
CareStarter (e.g.,
CareMap, CareStarter
App)
Primary Care
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26
Where does your EFMP-enrolled dependent primarily
obtain Primary Care services?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G03Q16]' (Did/do you have EFMP-enrolled pediatric
dependent(s) are in your family unit?)
Please choose only one of the following:
Direct care
Private sector care
Do not see a Primary Care provider
27
Have you established Primary Care since PCS’ing to
Travis AFB for your EFMP-enrolled dependent?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G03Q16]' (Did/do you have EFMP-enrolled pediatric
dependent(s) are in your family unit?)
Please choose only one of the following:
Yes
No
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Which of the following resources helped you most to
locate and establish Primary Care at Travis AFB for
your EFMP-enrolled dependent?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G05Q24]' (Have you established Primary Care since
PCS’ing to Travis AFB for your EFMP-enrolled dependent? )
Please choose only one of the following:
Primary Care at your previous installation
ECHO Case Manager
TRICARE or HealthNet provider directory
Travis EFMP Special Needs Coordinator
Materials from CareStarter (e.g., CareMap, CareStarter App)
None
Other, Pease describe. (Do not include any personal identifiable information.)
Other
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29 Please indicate how easy or difficult it was to get
Primary Care for your dependent based on the
following.
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G05Q24]' (Have you established Primary Care since
PCS’ing to Travis AFB for your EFMP-enrolled dependent? )
Please choose the appropriate response for each item:
Very
diffcult
Neither
Somewhat easy nor
difficult
difficult
Somewhat
easy
Very
easy
Provider waitlists
Provider accepting
patients
Distance
Needing new referral
30
How many providers did you contact in order to
schedule a Primary Care intake appointment for your
EFMP-enrolled dependent?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G05Q24]' (Have you established Primary Care since
PCS’ing to Travis AFB for your EFMP-enrolled dependent? )
Please choose only one of the following:
1
2
3
More than 3
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Were there any Primary Care providers whom your
EFMP-enrolled dependent needed to see that were
not included in the resource lists you used to locate
care?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G05Q24]' (Have you established Primary Care since
PCS’ing to Travis AFB for your EFMP-enrolled dependent? )
Please choose only one of the following:
Yes
No
32
Did you have to reach out to any of the following
resources for assistance locating Primary Care
services at Travis AFB for your EFMP-enrolled
dependent? Select all that apply.
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G05Q24]' (Have you established Primary Care since
PCS’ing to Travis AFB for your EFMP-enrolled dependent? )
Please choose all that apply:
Primary Care at your previous installation
ECHO Case Manager
TRICARE or HealthNet contact line
Travis EFMP Special Needs Coordinator
CareStarter
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33 How satisfied are you with the resources you used
to get Primary Care services for your EFMPenrolled dependent?
Only answer this question if the following conditions are met:
Answer was 'Yes' at question ' [G05Q24]' (Have you established Primary Care since
PCS’ing to Travis AFB for your EFMP-enrolled dependent? )
Please choose only one of the following:
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
34
Please describe why you are dissatisfied. Do not
include any personal identifiable information.
Only answer this question if the following conditions are met:
Answer was 'Dissatisfied' or 'Very dissatisfied' at question ' [G05Q30]' (How satisfied are you
with the resources you used to get Primary Care services for your EFMPenrolled dependent?)
Please write your answer here:
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Specialty Care
If you have more than one EFMP-enrolled dependent, please continue to complete the following
section based on the dependent who has the most complex care needs.
35
In the past 6 months, what Specialty Care services
did your EFMP-enrolled dependent need? Select all
that apply.
Please choose all that apply:
Behavioral Health (e.g., anxiety-related disorders, depressive disorders)
Neurodevelopmental Disorders (e.g., ADHD, autism, conduct disorders)
Other
Other:
36
Where does/do your EFMP-enrolled dependent
primarily obtain Behavioral Health Specialty Care
service?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
Direct care
Private sector care
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Have you established Behavioral Health Specialty
Care service at Travis AFB for your EFMP-enrolled
dependent?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
Yes
No
38
Which of the following resources helped you most to
locate and establish Behavioral Health Specialty Care
service for your dependent?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose all that apply:
Primary Care at your previous installation
Primary Care at Travis AFB
ECHO Case Manager
TRICARE or HealthNet provider directory
Travis EFMP Special Needs Coordinator
Materials from CareStarter (e.g., CareMap, CareStarter App)
None
Other, please describe. (Do not include any personal identifiable information.)
Other:
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How many providers did you contact in order to
establish an intake appointment for Behavioral Health
Specialty Care service for your EFMP-enrolled
dependent?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
1
2
3
More than 3
40
Were there any Behavioral Health Specialty Care
providers whom your EFMP-enrolled dependent
needed to see that were not included in the resource
lists you used to locate care?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
Yes
No
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Did you have to reach out to any of the following
resources for assistance locating Behavioral Health
Specialty Care services for your EFMP-enrolled
dependent? Select all that apply.
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose all that apply:
Primary Care at Travis
ECHO Case Manager
TRICARE or HealthNet contact line
Travis EFMP Special Needs Coordinator
CareStarter
42
Where does/do your EFMP-enrolled dependent
primarily obtain Neurodevelopmental
Disorders Specialty Care service?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
Direct care
Private sector care
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Have you established Neurodevelopmental
Disorders Specialty Care service at Travis AFB for
your EFMP-enrolled dependent?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
Yes
No
44
Which of the following resources helped you most to
locate and establish Neurodevelopmental
Disorders Specialty Care service for your dependent?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose all that apply:
Primary Care at your previous installation
Primary Care at Travis AFB
ECHO Case Manager
TRICARE or HealthNet provider directory
Travis EFMP Special Needs Coordinator
Materials from CareStarter (e.g., CareMap, CareStarter App)
None
Other, please describe. (Do not include any personal identifiable information.)
Other:
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How many providers did you contact in order to
establish an intake appointment
for Neurodevelopmental Disorders Specialty Care
service for your EFMP-enrolled dependent?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
1
2
3
More than 3
46
Were there any Neurodevelopmental
Disorders Specialty Care providers whom your EFMPenrolled dependent needed to see that were not
included in the resource lists you used to locate care?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
Yes
No
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Did you have to reach out to any of the following
resources for assistance locating Neurodevelopmental
Disorders Specialty Care services for your EFMPenrolled dependent? Select all that apply.
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose all that apply:
Primary Care at Travis
ECHO Case Manager
TRICARE or HealthNet contact line
Travis EFMP Special Needs Coordinator
CareStarter
48
Where does/do your EFMP-enrolled dependent
primarily obtain Other Specialty Care service?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
Direct care
Private sector care
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Have you established Other Specialty Care service at
Travis AFB for your EFMP-enrolled dependent?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
Yes
No
50
Which of the following resources helped you most to
locate and establish Other Specialty Care service for
your dependent?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose all that apply:
Primary Care at your previous installation
Primary Care at Travis AFB
ECHO Case Manager
TRICARE or HealthNet provider directory
Travis EFMP Special Needs Coordinator
Materials from CareStarter (e.g., CareMap, CareStarter App)
None
Other, please describe. (Do not include any personal identifiable information.)
Other:
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How many providers did you contact in order to
establish an intake appointment for Other Specialty
Care service for your EFMP-enrolled dependent?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
1
2
3
More than 3
52
Were there any Other Specialty Care providers whom
your EFMP-enrolled dependent needed to see that
were not included in the resource lists you used to
locate care?
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose only one of the following:
Yes
No
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Did you have to reach out to any of the following
resources for assistance locating Other Specialty Care
services for your EFMP-enrolled dependent? Select all
that apply.
Only answer this question if the following conditions are met:
Answer was at question ' [G06Q32]' (In the past 6 months, what Specialty Care services did
your EFMP-enrolled dependent need? Select all that apply. )
Please choose all that apply:
Primary Care at Travis
ECHO Case Manager
TRICARE or HealthNet contact line
Travis EFMP Special Needs Coordinator
CareStarter
Specialty Care Continued
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Please indicate how easy or difficult it was to get
Specialty Care for your dependent based on the
following.
Please choose the appropriate response for each item:
Very
difficult
Difficult
Neither
easy nor
difficult
Easy
Very
easy
Provider waitlists
Providers accepting
new patients
Distance
Needing new referral
55 How satisfied are you with the resources you used
to get Specialty Care services for your EFMP-enrolled
dependent received?
Please choose only one of the following:
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very Satisfied
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Please describe why you are dissatisfied. Do not
include any personal identifiable information.
Only answer this question if the following conditions are met:
Answer was 'Dissatisfied' or 'Very dissatisfied' at question ' [G08Q55]' (How satisfied are you
with the resources you used to get Specialty Care services for your EFMP-enrolled
dependent received?)
Please write your answer here:
57
Did you need to contact the Travis EFMP Office at any
point to help with identifying medical resources for
your EFMP Family member?
Please choose only one of the following:
Yes
No
EFMP Process
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How would you rate your stress level with regard to
identifying and establishing care for your EFMPenrolled dependent(s)?
Please choose only one of the following:
Extremely stressful
Somewhat stressful
Minimally stressful
Not at all stressful
59
Did the resources you used help to reduce your
stress?
Please choose only one of the following:
Yes
No
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Do you have suggestions for additional resources that
you think would help to locate and establish care for
your EFMP-enrolled dependent(s)? Do not include any
personal identifiable information.
Please write your answer here:
Thank you for completing this survey.
02-16-2024 – 15:28
Submit your survey.
Thank you for completing this survey.
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| File Type | application/pdf |
| File Title | MAX Survey - Exceptional Family Member Program (EFMP) Pilot Program Evaluation at Travis Air Force Base Survey |
| File Modified | 2024-04-03 |
| File Created | 2024-04-03 |