Parent/Family Survey - Hospital and Infant & Toddler Connection/Early Intervention/Part C Collaborative

Your response will help us understand how hospitals provide information to parents and families about the Infant & Toddler Connection of Virginia and Early Intervention/Part C. These programs provide services to infants and toddlers from birth through age two who are not developing as expected or who have a medical condition that can delay normal development. The survey is anonymous unless you request to be contacted. This information will only be used for performance improvement purposes. Thank you for your input. Questions, please contact Wanda Clevenger, wclevenger@vhha.com (804) 965-1202 or Tracey Edman, New Path Family Support Coordinator, tedman@thearcofva.org (804) 649-8481 ext. 112.

75% of the funding for this project was provided by the Virginia Board for People with Disabilities under the federal Developmental Disabilities and Bill of Rights Act. For more information on the Board, please contact: Virginia Board for People with Disabilities,1100 Bank Street, 7th Floor, Richmond, VA 23219, (800) 846-4464, or visit the Board’s website at www.vaboard.org

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* 1. In what city or county do you live (i.e., Richmond City)?

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* 2. Is English your primary language?

Yes

No, please provide primary language spoken below

Primary language spoken

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* 3. Are you currently receiving services from the Infant & Toddler Connection/Early Intervention/PartC?

Yes

Yes, I am receiving services but not sure if services are from the Infant & Toddler Connection/Early Intervention/Part C program.

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* 4. If you had a hospital or Neonatal Intensive Care Unit stay with your infant in the last 3 years, select the hospital from the drop down list or select other and note facility. If your hospital stay was 3 or more years ago, skip to question 14.

Other (please specify)

Questions 5 through 13 relate to your hospital or Neonatal Intensive Care Unit stay.

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* 5. Approximately how long was your infant's stay in the hospital or Neonatal Intensive Care Unit? Respond using any or all fields (for example, 20 days).

Days

Weeks

Months

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* 6. When was your infant discharged from the hospital or Neonatal Intensive Care Unit?

Discharged on or about

Date

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* 7. Were you provided with pamphlets or materials describing the Infant & Toddler Connection/Early Intervention/Part C program?

Yes

Yes, but not in my spoken language

I do not recall

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* 8. Was the Infant & Toddler Connection/Early Intervention/Part C program discussed with you?

Yes

Yes, but not in my spoken language and a translator was not provided.

No, the Infant & Toddler Connection/Early Intervention/Part C was not discussed with me

I do not recall

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* 9. If the Infant & Toddler Connection/Early Intervention/Part C was discussed with you, who had this conversation with you? Select all that apply.

Nurse

Doctor

Social Worker

Case manager or discharge planner

Physical Therapist, Occupational Therapist and/or Speech-Language Pathologist

March of Dimes NICU Family Support Program Coordinator

Infant & Toddler Connection/Early Intervention Part C manager

Another parent or family member

Infant & Toddler Connection/Early Intervention/Part C was not discussed with me.

I do not recall

Do you have suggestions for how we can improve?

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* 10. At or near the time of hospital discharge, did you receive a referral for the Infant & Toddler Connection/Early Intervention/Part C program?

Yes

I do not recall

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* 11. When preparing for discharge to home, did you receive teaching and/or information on developmental milestones for your infant?

Yes

Yes, but not in my spoken language

Please provide any comments related to improving discharge readiness and education.

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* 12. Do you feel you received enough information about the Infant & Toddler Connection/Early Intervention/Part C to understand how the program works?

Yes

What information would have helped you?

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* 13. Did you receive help understanding and requesting Medicaid, Medicaid Waiver and/or other payment programs?

Yes

Yes, but not in my spoken language.

What information would have helped you?

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* 14. If you received information on the Infant & Toddler Connection/Early Intervention/Part C, did the materials explain how this program differs from the medical model? The Infant & Toddler Connection/Early Intervention/Part C utilizes coaching and actively involves the parent or care giver. During Coaching, therapists show caregivers how to work with their child through daily activities in his/her natural environment (for example, in your home).

Yes

NA - did not receive any information on Infant & Toddler Connection/Early Intervention/Part C

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* 15. If you received or are currently receiving services from the Infant & Toddler Connection/Early Intervention/Part C, please identify the services below. Check all that apply.

Occupational Therapy

Physical Therapy

Speech Therapy

Vision Therapy

My infant/toddler did not receive any therapy services

Other (please specify)

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* 16. If you were not referred to the Infant & Toddler Connection/Early Intervention/Part C during your hospital or NICU stay but were referred at a later time, identify referral source.

Other (please specify)

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* 17. If your child received services from the Infant & Toddler Connection/Early Intervention/Part C, did you perceive these services to be beneficial?

Yes

Not sure

Describe your suggestions for improvement

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* 18. If you received services from the Infant & Toddler Connection/Early Intervention/Part C, were your child's developmental goals clearly communicated to you?

Yes

Not sure

Describe your suggestions for improvement

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* 19. If you would like to be contacted to provide additional feedback, please provide your information below.

Last name

First name

Phone number

Thank You!