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Your opinion is important! Please take a minute to complete the survey below. Your answers will be private and anonymous. The purpose of this survey is to get your opinions about accessing needed community-based health care services in your area.

The Department of Health will use the results of this survey and other information to identify challenges for young adults with special health care needs that can be addressed through community action. Thank you for taking the time to provide us with your input. If you have any questions, please contact us at CMS.CSHCN@flhealth.gov or (850) 245-4200.

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* 1. Your age:

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* 2. Do you self identify as having a special health care need?

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* 4. Ethnic group you most identify with:

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* 5. How do you pay for your health care? (please check all that apply)

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* 6. Please check all community-based resources you have accessed in the past year:

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* 7. Please check all community-based resources you needed but did NOT access in the past year:

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* 8. In the past year, how satisfied were you with your ability to access community-based resources that you needed in order to transition to adult health care?

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* 9. Please explain your answer to the above question:

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* 10. Please provide any recommendations on how to improve access to community-based resources necessary to make transition to adult health care:

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