Reminder/Recall Survey Name: Practice/Location Name: Street Address: City/State/Zip What type of practice are you located? Pediatrics Family Health Department Other Other: What is your practice geographical setting? Urban (a city or town, more densely populated) Rural (outside a city or town, less densely populated) Other Other What are your patient demographics to the best of your knowledge? Please include percent Medicaid, percent private insurance, percent English speaking, percent non-English speaking, if possible. Who to patients typically see? Their physician Whoever is available Other Other What type of REMINDER systems are used in your office to let adolescents and their parents know they missed their annual well child visit? (check all that apply) Reminder card given in person Phone reminder Mail reminder (letters or post cards) Text message reminder Patient portal reminder Email reminder Nothing Other Other: What type of RECALL systems are used in your office to remind adolescents and their parents to come to their annual well child visit? ? (check all that apply) Phone call Mail (letter or post card) Text message Patient portal Email Nothing Other Other: Which systems do you find to be the MOST helpful? Please explain. Which systems do you find to be the LEAST helpful? Please explain. Do you notice a certain type of reminder works better for different age groups? (e.g. texting works best for parents of infants, post cards work best for non-English speaking patients) What other resources are helpful when implementing reminder or recall systems? Please include any other notes you believe may be helpful in developing reminder and recall resources for this program.
