1. Title V Family Engagement Survey

The Title V Maternal and Child Health (MCH) Services Block Grant works to improve the health of women and children. The Georgia Department of Public Health (DPH) is asking for your help in determining which activities currently being used by Maternal and Child Health (MCH) programs best supports family engagement. Your feedback is very important to us and will be used to identify the areas that need to be strengthened.

Building strong relationships with families is vital to supporting the healthy development of children and overall family well-being. When families are engaged, vital partnerships are formed with a common focus - to help nurture families so children can grow and thrive.

This survey will help us assess your family engagement experience.

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* 1. Please provide your contact information below.

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* 2. What is your gender?

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* 3. Are you the head of your household?

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* 4. Which program(s) have you used or participated in within the last 12 months? (Check all that apply)

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* 5. In what county do you receive your services?

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* 6. For each statement below, please check the one answer that best describes your experience within the last 12 months. If you do not know, please select "I don't know/not applicable."

  Never Rarely  Sometimes Very often  Always Don't Know/Not Applicable
The program(s) gives me information about a diagnosis.
The program(s) asks me for my opinions about my care/treatment plan.
The program(s) works with me to make treatment choices.
The program(s) surveys me about the care I receive. 
The program(s) asks me to be a program adviser. 
The program(s) uses online resources to engage me.
The program(s) asks me to participate in activities to improve the program.
The program(s) holds focus groups to ask for my opinions about a health care issue.
The program(s) asks me how program money should be spent. 
The program(s) asks me to be on a committee to make decisions about resource sharing.

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* 7. For each statement below, please check the one answer that best matches the reasons why you or your family are not more involved with the programs.

  Strongly Disagree Disagree Neutral  Agree Strongly Agree
I know enough to care for myself/child/family.
I know enough to make healthcare choices.
My schooling prepared me to make my own healthcare choices.
It is easy to follow the program's policies.
My culture affects my healthcare choices.
What I hear from my friends and family affects my healthcare choices.
I have problems with insurance/ paying for medical services.
I learn all I need to know by going to town hall meetings and public hearings.
The program is not open when I am free. 
I have problems with the program's customer service.
I have problems with transportation to go to my appointments.
I work during the time the program is open. 
I have difficulty taking time off work to go to my appointments.

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* 8. Please list your suggestions to get patients and families more involved in MCH programs.

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* 9. Can we contact you for further information?

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