(Community School District #15, Brooklyn, NY)

In an effort to better involve parents/guardians in the delivery of health care services to their children, we would like to ask you a few questions regarding the health needs of your child.

Please take a few moments to answer the following questions. You do not need to put your name or your child’s name on this form.

1) Has your child/teen been to a doctor or nurse in the past year?

___Yes ___No


2) Are there barriers that make it difficult for you to take your child/teen to the doctor or nurse? (Check all that apply)

___It cost too much
___I don’t have a regular nurse or doctor
___I couldn’t take off from work
___The hours were not good for me
___It was hard to get an appointment
___I didn’t have insurance
___It was too far away
___None of the above
___Other (Please explain)


3) When would you like your child/teen to be seen by a health care professional? (Check all that apply)

___Once a year for a physical
___When they are sick
___When I have a concern for their health


4) In your opinion, what are some childhood/adolescent health problems/issues that concern you? (Check all that apply)

___lack of exercise
___dental health
___mental health
___stress management
___behavior problems
___genetic disability
___chronic headaches or stomachaches
___pregnancy prevention
___sexually transmitted diseases
___violent and aggressive behavior
___Other (please explain)


5) Does your child/teen get depressed or stressed out?

___Yes ___No


6) How do you view your or your child’s doctor or nurse? (Check all that apply)

___Easy to talk to
___Doesn’t pay attention
___Listens to me or my child
___Difficult to understand
___Makes me or my child feel uncomfortable
___Sees me on time
___Doesn’t see me on time
___Makes me wait a long time
___Other (please explain)


7) Did you know there was a School Based Health Center in your child’s school that provides comprehensive health care at no cost to you?

___Yes ___No


8) Are you familiar with the services at the School Based Health Center?

___Yes ___No


9) If your child/teen has not used the School Based Health Center, what are your reasons? (Check all that apply)

___I didn’t know there was a SBHC
___She/He has her/his own doctor
___She/he doesn’t need to go
___I don’t know what the services are that they provide
___Other (please explain)

10) If you do use the School Based Health Center, why do you use it? (Check all that apply)
___The hours are good for me and my child
___I don’t need to take time off from work to bring them to a
___I like the staff and my child likes the staff
___If my child gets sick at school, they will
be taken care of
___My child/teen stays home less because I know they will be taken care of at school
___I don t have to pay
___It’s easy to get an appointment
___I don’t have to wait a long time
___Other (please explain)


11) If you have used the School Based Health Center at any time, have you been satisfied with the services your child/teen has received?

___Very satisfied
___Mostly satisfied
___Somewhat unsatisfied
___Not satisfied (please explain)


Are there any services that you would like the School Based Health Center to provide?

Please explain: