[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-4.
In the last 12 months, how much of a problem, if any, was it to get a referral to a specialist that (PERSON) needed to see?

A BIG PROBLEM .......................... 1
A SMALL PROBLEM ........................ 2
NOT A PROBLEM .......................... 3
REF ................................... -7
DK .................................... -8
[Code One]

[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-4.
In the last 12 months, how much of a problem, if any, was it to get a referral to a specialist that (PERSON) needed to see?

A BIG PROBLEM .......................... 1
A SMALL PROBLEM ........................ 2
NOT A PROBLEM .......................... 3
REF ................................... -7
DK .................................... -8
[Code One]

[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-4.
In the last 12 months, how much of a problem, if any, was it to get a referral to a specialist that (PERSON) needed to see?

A BIG PROBLEM .......................... 1
A SMALL PROBLEM ........................ 2
NOT A PROBLEM .......................... 3
REF ................................... -7
DK .................................... -8
[Code One]

[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-4.
In the last 12 months, how much of a problem, if any, was it to get a referral to a specialist that (PERSON) needed to see?

A BIG PROBLEM .......................... 1
A SMALL PROBLEM ........................ 2
NOT A PROBLEM .......................... 3
REF ................................... -7
DK .................................... -8
[Code One]

[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-4.
In the last 12 months, how much of a problem, if any, was it to get a referral to a specialist that (PERSON) needed to see?

A BIG PROBLEM .......................... 1
A SMALL PROBLEM ........................ 2
NOT A PROBLEM .......................... 3
REF ................................... -7
DK .................................... -8
[Code One]

[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-4.
In the last 12 months, how much of a problem, if any, was it to get a referral to a specialist that (PERSON) needed to see?

A BIG PROBLEM .......................... 1
A SMALL PROBLEM ........................ 2
NOT A PROBLEM .......................... 3
REF ................................... -7
DK .................................... -8
[Code One]

[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-4.
In the last 12 months, how much of a problem, if any, was it to get a referral to a specialist that (PERSON) needed to see?

A BIG PROBLEM .......................... 1
A SMALL PROBLEM ........................ 2
NOT A PROBLEM .......................... 3
REF ................................... -7
DK .................................... -8
[Code One]

In the last 12 months, how much of a problem, if any,
was it to get a referral to a specialist that your child
needed to see?

A big problem ....................................
A small problem ................................
Not a problem....................................
My child didn't need to see a specialist in the last 12 months.......