We are trying to build a network for Head Start health managers in Maryland. Please take a little time to complete these few questions. Thank you.

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* 1. Name

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* 2. Title

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* 3. Email address

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* 4. Program

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* 5. Please list the names and email addresses for any other staff in your program that might benefit from participating in a Head Start health services peer support network.

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* 6. Please rate the following Head Start health service functions. 1 means you would like more support. 5 means you don't need any additional support. NOTE: All answers are confidential and will be used for planning purposes only.

  1 2 3 4 5 N/A
Physical Health & Wellness
Nutrition & Physical Activity
Oral Health & Wellness
Safety & Injury Prevention
Mental Health & Wellness
Family Health Literacy/Parent Communication
Services to Pregnant Women & Expectant Families
Children w/Special Health Care Needs
Sanitation & Hygiene
Health Services Advisory Committee
Staff Wellness
Sensory Screening
Policies & Procedures
Training staff & parents
Engaging families in their child's health
Engaging community health partners

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* 7. Do you have other health sand safety concerns for children and families in your community?

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* 8. What benefit would you like to see coming from a health manager network?

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* 9. Would you be interested in helping to get a health manager network started?

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