School-Based Health Center - Parent Survey
We are planning to open a school-based health center in the new Cañon City Middle School. Your responses to this survey will help us understand what kinds of student health services are needed, such as medical care, counseling services, dental care, etc.

As a parent or guardian of a Cañon City School District student, your opinion about needed health services is very important.

Cañon City School District, Solvista Health, and Valley-Wide Health Systems are part of the planning team for the new school-based health center. Students with a signed parental consent will be eligible to receive services at the School-Based Health Center.

A SBHC brings the healthcare provider into a school so students can avoid health related absences and receive the support they need to succeed in the classroom. SBHCs are staffed by a multi-disciplinary team of qualified medical and mental health professionals.

Services provided may include: physical exams, including sports physicals; immunizations; care for acute, minor injury and illness; management of chronic conditions such as asthma, allergies, and diabetes; counseling services; routine lab tests and throat cultures; prescriptions and medications; health wellness education; referral to community providers and agencies; and assistance to families with enrollment into Medicaid and CHP+.

Why School-Based Health Centers?
-Access to Health Care For All Students-
School-based health centers provide health care to all students of Cañon City schools who have parental permission, regardless of insurance coverage or ability to pay (often at no cost or low cost depending on services needed).

-Regular Preventive Care-
When health care is far away, expensive, or difficult to access, children are less likely to receive regular preventive care. School-based health centers offer care where the children are -- in schools.

-Keeping Children in School-
School-based health centers help keep children in school and ready to learn, treating acute and chronic health problems immediately and returning students to class as soon as possible.

-Strong Parent and School Support-
When parents give permission for their child to be seen at a school-based health center, they no longer have to miss work to care for minor problems. They know that their child will receive prompt attention from health providers trained at working with youth. School administrators and teachers are extremely supportive of school-based health centers because health centers allow them to focus on their role of educating students who are healthy and ready to learn.

To help us plan for the school-based health center, we would like you to answer a few questions about the health needs of your child. This information will help us decide what types of services and programs to offer at the school-based health center.

Your answers are completely confidential. You do not need to put your name anywhere on this form.
What is your preferred language at home? *
Your answer
Which school(s) in RE-1 Cañon City do your children attend (check all that apply) *
Required
What type of residence do you and your student live in? (Select one) *
What is your household income range? *
1. At the school(s) your children attend, what are the biggest health concerns or issues that children/adolescents face? (Check all that apply) *
Required
2. What health problems or concerns have your child/children had in the past month? (Check all that apply) *
Required
3. Have you been told by a doctor that your child(ren) has any of the following chronic health problems? (Check all that apply) *
Required
4. Where do you regularly take your child(ren) for health care? (Check all that apply) *
Required
5. When was the last time your child(ren) had a thorough physical exam? *
6. Do you have a regular source of dental care for your child(ren)? *
7. Do you have someone you could take your child(ren) to for counseling services for behavioral problems? (e.g., unusual or extreme fears, depression, nervousness, behavioral issues) *
8. Have you had any problems getting health care, mental health care or dental care for your child(ren)? (if yes, select all that apply) *
Required
9. If yes, what are the reasons you have had problems or not been able to get these services for your child(ren)? (Check all that apply)
10. How do you currently pay for health services for your child(ren)? *
11. When you take your child to the doctor, counselor or dentist, how often do you have to miss work? *
12. When you take your child to the doctor, counselor or dentist, how often do they have to miss school? *
13. Once the School-Based Health Center open at CCMS, how likely would your child(ren) be to use the Center? (Check one) *
14. At what hours would your child(ren) be most likely to use the Center? (Check all that apply) *
Required
15. When going to a medical or dental appointment, how would you get there? (Check one) *
16. How long does it take you to get there? *
What is your postal ZIP code? *
Your answer
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