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?

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

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). 

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

Discharged on or about 

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

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

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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.

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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?

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

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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?

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

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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).

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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.

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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?

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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? 

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

Thank You!

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