NJ Epilepsy Task Force Survey Questionnaire


We appreciate your input with the following questionnaire. All responses will be tabulated and compiled to aide in our  recommendations to the Governor of New Jersey.

Please note that all responses are confidential. Your zip code is required for averages, only.

NOTE:  You must reside in the State of New Jersey to participate in this survey questionnaire.


Questionnaire


This question is required
  1. New Jersey Zip Code for where you reside?


This question is required
  1. My relationship with Epilepsy is:

I have Epilepsy
I am a caregiver of someone with Epilepsy
I am a health care provider who cares for persons with Epilepsy
Other


This question is required
  1. Upon learning of the Epilepsy diagnosis, how did you obtain information regarding programs, support groups, medications and other resources:

Neurologist
I relied mostly on the internet
I relied mostly on recommendations and input from friends and relatives.
I am not aware to date of programs and resources available to me.
Primary Care Doctor.

This question is required
  1. (Parent) Do you feel that your child’s teacher, day care workers or school personnel are adequately trained in emergency protocol, warning signs and types of seizures/Epilepsy?

    (Adult) Do you feel that your place of employment, adult day care or school are properly trained in the emergency  protocol, warning signs and types of seizures/Epilepsy?


Yes, I have not had any problems with personnel being trained.
No, personnel are aware, but not adequately trained.
No, personnel are not aware and I have had to instruct them on protocol and signs.
Not Applicable.

This question is required
  1. Generic Medications vs. Brand Name Medications

I want the option to remain on my name brand medication to avoid the possibility of breakthrough seizures.
I would want the pharmacist to notify me if I am having the substitution and/or if they are replacing the generic with another generic.
I have no opinion on this topic.
Not Applicable.

This question is required
  1. Driving: I would like the law to change so that the doctor does not have to report me and it will be my responsibility to obey the law

Yes.
No.
Not Applicable.

This question is required
  1. Driving: By law, your doctor in New Jersey must report you to the MVC if you tell them that you have seizures

I was unaware my doctor could report me to the MVC.
I was aware my doctor could report me to the MVC, but I am still honest with my doctor regarding my seizures.
It is troubling that my doctor could report me to the MVC , but I am still honest with my doctor regarding my seizures.
I might not report a breakthrough seizure to my doctor to avoid losing my license or so that I may have my license returned.
Not Applicable.

This question is required
  1. What type of doctor takes care of your Epilepsy?

Primary care doctor (internist, family doctor, peditrician).
Neurologist.
Epileptologist (Epilepsy specialist).
None.
Not Applicable.

  1. What do you feel is the biggest obstacle(s) which you are facing in regards to Epilepsy?

  2. ( Optional )

  1. What solutions/changes would you recommend regarding Epilepsy as a State of New Jersey resident?


  2. ( Optional )

  1. Medical Marijuana is a topic at the forefront of discussions for the treatment of Epilepsy.  What are your thoughts on this topic?

  2. ( Optional )

This question is required
  1. I would like someone to contact me

Yes
No

  1. I prefer to be contacted by


  2. ( Optional )
Email

Phone

Mail

  1. Mailing Address

  2. ( Optional )