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* 1. Please indicate your age range:

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* 2. Please indicate your gender:

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* 3. Please indicate the range of your household’s total income:

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* 4. What is your mother tongue (first language learned and still understood)?

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* 5. Which language is most often spoken in your home?

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* 6. Where were you born?

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* 7. Please enter your postal code:

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* 8. Do you have children?

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* 9. In what type of school is your oldest school-age child enrolled?

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* 10. In the last year, how many times have you, or a member of your family, used publicly-funded health services in your area (e.g., check-up, emergency room visit, hospitalization)?

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* 11. When you used publicly-funded health care in the last year, were services provided to you in French?

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* 12. Do you have a family doctor?

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* 13. Are you able to discuss your health with your doctor in French with sufficient ease?

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* 14. Do staff who greet you at your doctor’s office speak French?

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* 15. Have you tried to locate a French-speaking family doctor in your area?

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* 16. Regarding the last time you used the services of a hospital in your area, including for an emergency, either as a patient or to provide support to a patient, please rate the degree of difficulty you experienced in accessing French-language services? (If you have not used hospital services in the last two years, please skip to question 16.)

  Did not try Impossible Difficult Easy Very Easy Does not apply
Reception / Information
Admissions
Health care providers other than physicians
Physicians
Support services

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* 17. If you could choose, which language would you prefer to speak when dealing with the health care system?

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* 18. Do you happen to know a French-speaking health care provider in your area?

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* 19. If you do, you can help others in your area find him or her by listing the provider’s name and contact information below:

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