1. Check the category or categories that describe you:

• Individual with a disability
• Child or youth with special health care needs (CYSHCN)
• Parent or other family member of individual with a disability or CYSHCN
• Educator/para-educator
• Medical professional
• Representative of a public or private agency
• Other Please enter an 'other' value for this selection.

2. Check your age category: 

• 0 – 18 years old
• 19 – 29 years old
• 30 years and older

3.  Are you currently attending school?

• Yes
• No

4. What is the highest level of school you have completed?

• Elementary/primary school
• High school
• Technical/vocational school
• University/college
• Post-university/graduate school
• Don’t know

5. Where did you use the workbook? (Check all the answers that apply.)

• Home
• School
• Medical provider’s office
• Vocational Rehabilitation office
• Other (please describe) Please enter an 'other' value for this selection.

6. Which version of the workbook did you use? (Check all the answers that apply.)

• Paper copy (also called a “hard copy”)
• DVD
• Online version (on a computer)
• Other (please describe) Please enter an 'other' value for this selection.

7. Altogether, how much time did you spend using the workbook?

• Less than 1 hour
• Between 1 and 3 hours
• Between 3 and 6 hours
• More than 6 hours

8. Why were you using the workbook? (Check all the answers that apply.)

• Planning my own health care transition
• Planning my child’s health care transition
• Planning a family member’s health care transition
• Planning a student’s health care transition
• Planning a patient’s health care transition
• Research
• Just curious
• Other (please describe) Please enter an 'other' value for this selection.

9. Did anyone help you use the workbook?

• No
• Yes

10. If someone helped you use the workbook, check who:

• Parent
• Other family member
• Friend
• Teacher or para-educator
• Medical professional
• Other (please list) Please enter an 'other' value for this selection.

11. If you are a medical professional, teacher, or other professional using the workbook in your practice, with how many students/clients/patients have you used the workbook?

• 1
• 2-4
• 5-9
• 10 or more

12. Please rate how easy or difficult the workbook is to understand:

• Very easy
• Easy
• Not sure
• Difficult
• Very Difficult
• Comments? Please enter an 'other' value for this selection.

13. Please rate how easy or difficult the workbook is to use:

• Very easy
• Easy
• Not sure
• Difficult
• Very difficult
• Comments? Please enter an 'other' value for this selection.

14. Did the workbook increase your knowledge of health care transition planning for young adults with disabilities?

• Yes
• No
• Comments? Please enter an 'other' value for this selection.

15. Do you think what you learned from the workbook will help you in your life and/or at your job?

• Yes
• No
• Maybe
• Comments? Please enter an 'other' value for this selection.

16. Was enough information included in the workbook?

• Yes
• No – not enough information
• No – too much information
• Comments? Please enter an 'other' value for this selection.

17. Which workbook format do you prefer?

• Paper copy (also called a “hard copy”)
• DVD
• Online version (on a computer)
• Other (please describe) Please enter an 'other' value for this selection.
• Don't know

18. Overall, how satisfied were you with the workbook?

• Very satisfied
• Satisfied
• Undecided
• Dissatisfied
• Very dissatisfied
• Comments? Please enter an 'other' value for this selection.