IEIC Referral Tracking Form 19

Purpose of Survey:

To increase the number of referrals to the HMG line for comprehensive services.
To identify where referrals are consistently coming from.
To increase awareness of HMG to referral sources.

Please complete the below survey only for B-2 (Part C) Referrals.
Who is included? All students up to the age of 3 (3rd birthday).

Questions:
Christian Wernau at 507-775-2037 or cwernau@zumbroed.org.

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* 1. Reporters Name:

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* 2. List School Districts/SEAU

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* 3. Which quarter are you reporting for?

Quarter 1 - July 1 through September 30, 2018

Quarter 2 - October 1 through December 31, 2018

Quarter 3 - January 1 through March 31, 2019

Quarter 4 - April 1 through June 30, 2019

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* 4. How many total referrals did you receive this quarter?

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* 5. How many of the above referrals came from HMG?

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* 6. The number of referrals from each of the following sources?

Parent/Family

Primary Medical Physician

Audiology

Medical Social Worker

NICU

Public Health Departments (including nurses, dieticians, WIC, FAP, home visiting program)

Department of Human Services (social workers including child protection and PSOP)

Family Child Care Providers (including licensed, unlicensed, family and friends)

Center-based Daycare

Head Start

ECFE Programs / Learning Readiness Programs

ECSE Programs

Community Preschools

Other