54. Did someone help you fill out this form? WE'D LIKE TO BEGIN BY ASKING WHAT KINDS OF THINGS YOU LIKE TO
NO YES (who?)
1. Which of the following do you do outside of school: (check all that apply)
_____________________________________________________________________________________________ Community activities (4-H, Scouts...) Movies, plays, concerts
General Comments (use next page if necessary) Church activities Watch T.V.
Camps Computer- games, internet
Outdoor activities Play musical instrument
School clubs Listen to music, read, hobbies
Play sports
Watch sports Other (please list)
2. What things do you like to do with your friends?
3. What do you hope to be doing in the next five years?
4. Has anyone ever asked you this question (number 3) before?
NO YES (who?)
5. Do you have any concerns about being involved in activities
after you finish school?
NO YES (what?)
6. What has helped you the most in being involved in activities?
7. What has kept you from being involved in activities?
8. How do people you know describe you?
9. Who do you look up to?
10. Do any of your friends have a long-term health condition?
NO YES
11. Does your health condition influence how you spend time with your friends?
NO YES (how?)
8 1
IKE TO DO.
bies
12. Are you able to let people know what your needs and thoughts are? LAST, WE HAVE SOME QUESTIONS TO HELP US LEARN MORE
YES SOMETIMES NO ABOUT WHO YOU ARE.
13. Are you aware of resources available in your community that can help you? 48. How old are you? _______________
NO YES (examples)
49. What is your gender?
Male Female
NOW LET'S TALK ABOUT SCHOOL, WORK, & YOUR FUTURE.
50. Do you have any of the following: (check all that apply)
14. Are you in school?
YES (grade _____ ) NO (last grade ____ ) HOME SCHOOL Attention deficit disorder (ADHD) Respiratory (asthma, cystic fibr
Seizure disorder (epilepsy) Kidney/urinary
15. Are you absent from school several days a month? Bleeding disorders Mentally handicapped
NO YES (reasons) Blind or visual impairment Muscular Dystrophy
Deaf or hard of hearing Orthopedic (club foot, limb pro
16. What types of work and chores have you done at home, in your community, and Impaired ability to speak Weakness/paralysis
at school? Diabetes/endocrine/metabolic (thyroid) Spinal cord injury
Cancer Burn injury
Cleft lip/palate Cerebral palsy
Emotional/mental health problems Spina Bifida
17. Have you ever had a job (volunteer or paid) Stomach or intestinal Scoliosis
NO YES (what did you do?) Heart condition None of the Above
18. How old were you when you had your first volunteer or paid job?_________ Other (please list)
19. Do you have a paying job now?
NO YES (what do you do?) 51. Which of the following describes the area you live in? (check one)
Country Suburb of a large city
20. In the NEXT FIVE YEARS do you plan to: (check all that apply) Small town Large city (more than 50,000)
Large town/small city (less than 50,000)
Attend a school-to-work program Do volunteer work
Graduate from high school/ get GED Work with vocational rehabilitation for job training
Attend college Work part-time 52. How long have you lived in this area?______________________
Attend a vocational or technical school Work full-time
Go into the military
53. How many people live in your house?_____________________
Other (please list)
2 7
E
cystic fibrosis)
d
t, limb problems)
y
n 50,000)
40. What things are important for you to do in order to stay healthy? 21. What kind of job do you want to do when you grow up?
41. Which of these things do you do regularly? 22. Would you need any special equipment to do this job?
NO YES (what?)
42. Do you know what to do in case of an emergency? 23. What else might you need to do this job?
YES NO
43. How many times a year do you see a doctor or go to a clinic? _______________
24. Are there jobs like this in your community?
44. What concerns do you have about your care after you are too old to go to NO YES
the Commission Clinics?
25. Would you be willing to move in order to take a job?
YES NO (reasons)
45. Has anyone at the Commission referred you to any doctors or clinics that care for adults? 26. Is planning for your future important to you?
NO YES (who? ) NO YES
46. Have you seen or contacted that person or clinic? 27. I have talked about my future with:
YES NO (reasons) YES NO
My parents/ family
School counselors/ teachers
School programs/ class
47. To plan for my ADULT I do I have I have thought I Commission for Children
health care needs: not not thought about it, but have with Special Health Care Needs
need about it not found found Other:
A doctor for general care (ear aches, physical)
A doctor for my specialty care (orthopedics 28. Who or what has been the most helpful in planning for your future?
gynecology, urology)
A clinic I can go to
Therapy- PT, OT, RT, ...
Mental Health Services
Special equipment 29. What have been the biggest problems in planning for your future?
Medications
Supplies
Insurance or other way to pay for medical care
Other (please list)
6 3
NEXT LET'S TALK ABOUT INDEPENDENCE AND YOU!! NOW, WE'D LIKE TO ASK ABOUT YOU AND YOUR HEALTH.
30. Do you NOW (check all that apply): 33. Have you received information about the following: (check all that apply)
Diet Long-term effects of your health condition on your bo
Make your own decisions Live with your family Drive a car Exercise Dating
Fix your own meals Live with roommate(s) Have a vehicle you can use Smoking Marriage
Do your own laundry Live alone Use public transportation Alcohol Having Children
Do your own house cleaning Receive SSI or other Find ways to get where you Street drugs Birth control/ Reproductive Health
Manage your own money financial help need to be Safety Passing on a condition or illness to your children
Immunizations None of the above
Other (please list)
34. Do you have a long-term health condition?
NO YES (what?)
31. In the NEXT FIVE YEARS would you like to be able to (check all that apply):
35. How old were you when you developed this? ______________________
Make your own decisions Live with your family Receive SSI or other financial help
Go to school Live with roommate(s) Receive financial aid for school 36. Are you able to explain this condition to others? NO
Have a job Live alone Drive a car
Fix your own meals Get married Have a vehicle you can use 37. Do you use any special equipment or need special supplies to manage your
Do your own laundry Have a family Use public transportation health condition? NO YES (what?)
Do your own house Manage your own money Find ways to get where you
cleaning need to be
Other (please list)
38. This is how I do the following: Alone With a With a
little help of help
32. What help do you need to increase your independence? (check all that apply) Walking/moving around
Transferring (like from a chair to a bench)
Vocational education Transportation Communicating/talking
Going to college Driver's education Writing
Getting a job Counseling Grooming (bathing, getting dressed, ...)
Managing money Support groups Daily health care procedures
Not living with your family Community recreation Using special equipment
Housing/vehicle modifications Finding health insurance Taking medications
Knowing when you are healthy or getting sick
Other (please list)
39. What other activities would you like to be able to do?
Do you know where to find this help?
NO (reasons ) YES (where? )
4 5
n on your body
hildren
YES
With a lot
of help
KENTUCKY COMMISSION FOR
CHILDREN WITH SPECIAL
HEALTH CARE NEEDS
TEEN SURVEY
This survey is about teens and your needs as you move into your young adult years
Thank you for your time and effort with this survey. We need your ideas to help us plan good programs.
Your help is greatly appreciated. Please take a few moments to answer these questions and return the survey to us
rs.
s.