Survey Children

Child’s Super Shot Patient Questionnaire
Rev. 06/16
Super Shot is a not for profit organization. Please help us to meet our reporting obligations by answering the following questions. All information is confidential and for
reporting purposes only. (Super Shot es una organización sin fines de lucro. Ayúdenos a cumplir con nuestras obligaciones informativos respondiendo las siguientes preguntas. Toda la
información es confidencial y con fines informativos solamente.)
O Medicaid A child who has any form of Medicaid insurance.
O American Indian/Alaskan Native A child who identifies as an American Indian or Alaskan Native,
regardless of insurance.
O No Health Insurance A child who does not have health insurance.
O Insurance Does Not Cover Vaccines
• A child who has commercial (private) health insurance but the coverage does not include vaccines
• A child whose insurance covers only selected vaccines
• A child whose insurance caps vaccine coverage at a certain amount
O Fully Insured A child who has health insurance which provides coverage for vaccines.
O below (por debajo de) $11,880
O $11,881 - $24,300
O $24,301 - $36,450
O $36,451 - $48,600
O $48,601 - $60,750
O $60,751 - $72,900
(Mensaje de texto)
(Refereria un amigo a la clinica Super Shot)
23. How did you get to the Super Shot clinic? (¿Cómo llegó a la clínica Super Shot?)
O Citilink Bus (Ómnibus Citilink) O Assistance Van/Bus (Camioneta/Ómnibus de asistencia) O Dropped off by family/friend (Me trajo un amigo o familiar)
O Drove my vehicle (Conduciendo mi vehículo) O Walk (Caminando) O Bike (En bicicleta)
Clinic Use Only:(Para uso de la clínica solamente:)
Needs Interpreter (Necesita intérprete) ________
ABC ________