FOCALplus Eligibility Survey

Please complete the survey below.

Thank you!

Thanks for interest in the FOCALplus Teen Driver Training at Cincinnati Children's Hospital. This training program is not a good fit for all teens and we want to make sure that this training will be safe for your teen. This survey is going to ask you some questions to make sure that this training in right for them. If based on your responses, your teen is not a good fit for this training, the survey will explain why this training may not be safe for your teen. If it is a good fit for your teen at the end it will have you complete some information so our scheduling can reach out to schedule the training and process the $500 payment.

* Parent First Name

* Parent Last Name

* Parent Phone

* Parent Email

* Participant First Name

* Participant Last Name

* Participant Birthdate

* How did you hear about FOCALplus?

* If you answered "Other" above, please let us know how you heard about FOCALplus.

During September – June, most patients want to be scheduled during the after-school hours and weekends. If you are able to schedule during the weekday daytime hours (8am-3pm), please check here as we may be able to get you scheduled sooner.

* Primary Scheduling Time

Morning

Afternoon

Evening

* Secondary Scheduling Time

Morning

Afternoon

Evening

* Least Preferred Scheduling Time

Morning

Afternoon

Evening

* Has teen ever been diagnosed with epilepsy?

Yes

Driving simulation has the potential to trigger epileptic seizures. It is not safe to have your teen drive in the driving simulator which is an essential part of the training.

Click here to return to the FOCALplus Teen Driver Training page

* Has teen had a traumatic brain injury or concussion in the last 30 days?

Yes

It is not a good idea to have your teen drive in the driving simulator so soon after their TBI. The driving simulator may trigger headaches, dizziness, fatigue, or other TBI-related symptoms. We'd prefer to wait for 30 days after their TBI. Please call our intake office back when it has been 30 days since your teen's TBI and we will have you complete this survey again.

Click here to return to the FOCALplus Teen Driver Training page

* Does teen wear corrected lenses for their vision?

Yes

* Does your teen wear contacts?

Yes

* Can teen read text from phone at an arm's length away while not wearing their glasses?

Yes

Part of the training will require that your teen read test approximately an arm's length away while not wearing glasses. If they can't read that text, your teen is not going to be able to complete the training. Perhaps call us back if your teen is prescribed contact lenses or has their vision corrected.

Click here to return to the FOCALplus Teen Driver Training page

Record Type Id

Owner Id

How often does teen experience NAUSEA during the following activities?

* Automobile driving

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Amusement rides

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Air travel

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Ship travel

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Computer usage

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Simulators

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

How often does teen experience HEADACHES during the following activities?

* Automobile driving

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Amusement rides

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Air travel

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Ship travel

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Computer usage

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Simulators

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

How often does teen experience DIZZINESS during the following activities?

* Automobile driving

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Amusement rides

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Air travel

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Ship travel

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Computer usage

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

* Simulators

Never

Rarely

Sometimes

Nearly Always

Unknown or Not Applicable

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FOCALplus Eligibility Survey

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