NELA SCAF Pre-Pilot Survey

We’re collecting this information about your child’s past Emergency Department experience at the beginning of the pilot in order to establish a baseline to measure program effectiveness. You’ll need to complete this survey for your child to be confirmed for participation.  

Please answer the following questions with your child’s last Emergency Department (ED) visit in mind. Note: throughout the survey we’ll refer to an Emergency Department as “ED.”

Your individual answers to this survey will be kept completely confidential. Only aggregated, non-identifiable data on the effectiveness of the pilot will be shared.

SCD - NELA SCAF Pre-Pilot Survey
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Participant/Child's Information

Child's Name

Parent/Guardian Information

Parent/Guardian's Name

Latest ED Experience

Answer these questions with your child's latest ED visit in mind.

Had your child been seen at this Emergency Department prior to this last visit?

Using the scale below, have your child rate their pain at the time of ED visit from 0 to 10.

Choose the number that corresponds to the image your child selected on the pain scale.
After seeing the doctor, how long did your child wait before receiving their first pain medication?
How often was your child's pain re-assessed?
Did you tell the ED staff the name of your child's regular doctor and/or hematologist?
How responsive was ED staff to the provider information you gave them?
Did you feel “heard” by the ED staff?
Do you feel your child was treated with respect?
Was your child's pain or other concerns adequately addressed?
Does your child have a doctor prescribed SCD pain plan?
Were you offered the opportunity to speak to a patient advocate?
Did you ask for a patient advocate?
Was your child admitted to the hospital for further treatment?
Was a pain plan discussed during your visit?
How would you rate your child's overall ED experience with this visit?

Thank you! Once your child is enrolled in the program, you’ll report all ED visits during the pilot here: Post-ED Visit Survey.

If you have any questions about the pilot, please contact the program administrator at nelapilot@medicalert.org or call us on 1-800-432-5378.

This program is supported by the Louisiana Department of Health.

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