| Children’s Services - Parents Questionnaire |
| 1 | What was your reason for attending the clinic?
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| Additional health or specialist requirements |
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Preferred not to have vaccination in school |
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| Support required from a parent/guardian |
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Absent on the day of the school session |
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| Unable to have vaccination at school session due to medical reasons |
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Late consent form |
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| Not educated in a school setting |
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Other (please specify) |
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| N/A |
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| 2 | Was your child treated with kindness & respect?
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| 3 | Were you treated with kindness and respect?
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| 4 | Were you provided with clear information about your child’s care and treatment?
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| 5 | Did you receive timely information about your child’s care and treatment?
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| 6 | Did you have confidence and trust in the staff member that saw your child today?
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| 7 | Was the location suitable for your child’s needs?
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| 8 | How long after the stated appointment time did the appointment start?
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| 9 | Overall, how was your experience of our service ?
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| 10 | Thinking about your child’s recent outpatient appointment, please can you tell us why you gave this answer?
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| 11 | How likely are you to recommend this department to your friends and family ?
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| About Your Child |
| 12 | Which of these best describes your child’s ethnic background?
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| 13 | White
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| 14 | Asian / Asian British
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| 15 | Mixed / multiple ethnic groups
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| 16 | Black / African / Caribbean / Black British
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| 17 | Other ethnic group
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| 18 | Does your child have any physical or mental health conditions, disabilities or illnesses that have lasted or are expected to last 12 months of more?
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| 19 | Does your child have any of the following? (Select ALL conditions that have lasted or are expected to last for 12 months or more)
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| Attention Deficit Hyperactivity Disorder (ADHD) |
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Autism or autism spectrum condition |
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| Blindness or partial sight |
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Bowel condition, such as Crohn’s |
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| Breathing problem, such as asthma |
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Cancer in the last 5 years |
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| Chromosomal condition, such as Down’s syndrome or Prader-Willi |
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Deafness or hearing loss |
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| Diabetes |
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Heart problem |
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| Joint problem |
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Kidney or liver disease |
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| Learning disability |
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Mental health condition |
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| Neurological condition, such as epilepsy |
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Physical mobility condition |
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| Another long-term condition |
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None of the above |
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| Prefer not to say |
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| 20 | Thinking about your answers to the previous questions in the About Your Child section do you feel your child has experienced any barriers when accessing our services as a result of their protected characteristics?
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| 21 | If you answered 'Yes' or 'Yes, to some extent' to the previous question could you please let us know the barriers you have experienced:
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