Developmental Screening Survey_Family Medicine Providers

Mississippi State Department of Health (MSDH) Child and Adolescent Health Division is collecting data for Maternal Child Health Block grant objectives related to increasing health maintenance visits,and developmental screening for autism and other developmental delays in the state. Please take a few minutes to provide us with the screening tools used consistently in your practice. The survey is only one page. Only your de-identified data will be used for aggregate data collection. We greatly appreciate your participation. You will be entered into a drawing for Bright Futures 4th Edition manual and Pocket Guide.

Question Title

* 1. What is your gender?

Female

Male

Question Title

* 2. What is your occupation?

Question Title

* 3. What is your area of practice ?

Question Title

* 4. What is your practice type?

Question Title

* 5. Where do you practice (What County)?

Question Title

* 6. Do you use Bright Futures Guidelines for Routine Health Maintenance screening ?

YES

I'm not familiar with the guidelines

N/A (This is not applicable to my practice)

Question Title

* 7. What Developmental Tool is used for Routine Pediatric Health Maintenance ?

Question Title

* 8. What is the Developmental screening tool used for Autism in your practice?

MCHAT (Modified Checklist for Autism in toddlers)

MCHAT-R/F

Screening Tool for Autism in Toddlers and Young Children (STAT)

Other (please specify)

Question Title

* 9. Where do you refer your abnormal developmental screens?
(Select all that apply)

UMMC Child Development Center

University of Southern Mississippi Institute for Disabilities Study

First Steps Early intervention Program

Other (please specify)

Question Title

* 10. During routine health maintenance/well child visits, I screen for...

	Rarely	Sometimes	Most of the Time	All of the Time	N/A
Adolescent depression	Adolescent depression Rarely	Adolescent depression Sometimes	Adolescent depression Most of the Time	Adolescent depression All of the Time	Adolescent depression N/A
Maternal depression	Maternal depression Rarely	Maternal depression Sometimes	Maternal depression Most of the Time	Maternal depression All of the Time	Maternal depression N/A
Lead Exposure: Using the Verbal Lead Risk Assessment 6 months - 6 years	Lead Exposure: Using the Verbal Lead Risk Assessment 6 months - 6 years Rarely	Lead Exposure: Using the Verbal Lead Risk Assessment 6 months - 6 years Sometimes	Lead Exposure: Using the Verbal Lead Risk Assessment 6 months - 6 years Most of the Time	Lead Exposure: Using the Verbal Lead Risk Assessment 6 months - 6 years All of the Time	Lead Exposure: Using the Verbal Lead Risk Assessment 6 months - 6 years N/A
Lead Exposure: Obtaining Blood lead levels at 12 AND 24 months in Medicaid eligible population	Lead Exposure: Obtaining Blood lead levels at 12 AND 24 months in Medicaid eligible population Rarely	Lead Exposure: Obtaining Blood lead levels at 12 AND 24 months in Medicaid eligible population Sometimes	Lead Exposure: Obtaining Blood lead levels at 12 AND 24 months in Medicaid eligible population Most of the Time	Lead Exposure: Obtaining Blood lead levels at 12 AND 24 months in Medicaid eligible population All of the Time	Lead Exposure: Obtaining Blood lead levels at 12 AND 24 months in Medicaid eligible population N/A
Child and Adolescent Obesity/Risk factors	Child and Adolescent Obesity/Risk factors Rarely	Child and Adolescent Obesity/Risk factors Sometimes	Child and Adolescent Obesity/Risk factors Most of the Time	Child and Adolescent Obesity/Risk factors All of the Time	Child and Adolescent Obesity/Risk factors N/A
Adolescent substance abuse	Adolescent substance abuse Rarely	Adolescent substance abuse Sometimes	Adolescent substance abuse Most of the Time	Adolescent substance abuse All of the Time	Adolescent substance abuse N/A

List Barriers to any of the screenings

Question Title

* 11. Are you a medical home for children or adolescents?

Yes

Question Title

* 12. Do you have any other comments, questions, or concerns?

Question Title

* 13. Enter your Contact number/email here if you would like to enter drawing for Bright Futures, 4th Edition.

Thank you for your participation!!
Click DONE

Question Title

* 1. What is your gender?

Question Title

* 2. What is your occupation?

Question Title

* 3. What is your area of practice ?

Question Title

* 4. What is your practice type?

Question Title

* 5. Where do you practice (What County)?

Question Title

* 6. Do you use Bright Futures Guidelines for Routine Health Maintenance screening ?

Question Title

* 7. What Developmental Tool is used for Routine Pediatric Health Maintenance ?

Question Title

* 8. What is the Developmental screening tool used for Autism in your practice?

Question Title

* 9. Where do you refer your abnormal developmental screens?(Select all that apply)

Question Title

* 10. During routine health maintenance/well child visits, I screen for...

Question Title

* 11. Are you a medical home for children or adolescents?

Question Title

* 12. Do you have any other comments, questions, or concerns?

Question Title

* 13. Enter your Contact number/email here if you would like to enter drawing for Bright Futures, 4th Edition.

* 9. Where do you refer your abnormal developmental screens?
(Select all that apply)