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1. Provider Service and Supports Information

 
This survey provides the opportunity for providers to be listed in a database that details their unique sets of skills, abilities and experiences in supporting people with intellectual disabilities. Please provide information as requested indicating all services and supports that you currently have the capacity to offer.

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* 1. Please provide the date and time you are providing this information.

Date
Time

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* 2. Please provide your agency contact information.

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* 3. Please check all services provided by your agency.

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* 4. Please indicate your years of experience providing each service.

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* 5. Please provide location of services by Health Planning Region.

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* 6. If you provide RESIDENTIAL SERVICES, please list the types you provide.

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* 7. Please check all SPECIAL EQUIPMENT OR OTHER ACCOMMODATIONS with which staff at your agency have experience.

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* 8. Please indicate the availability or willingness of your agency to provide trained staff familiar with INTENSIVE MEDICAL MONITORING OR SUPPORTS to individuals who have chronic medical conditions and require technology or care such as feeding via tube, C-Pap machine, aspiration prevention, diabetic care, colostomy care, etc.

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* 9. Please check all information related to NURSING AVAILABILITY for Intensive Medical Monitoring and Care.

  Nurse available on staff. Nurse available on contract.
NURSING

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* 10. Please indicate if your agency has staff experienced with responding to individuals with high BEHAVIORAL SUPPORT needs (e.g., aggression toward others, SIB, inappropriate sexual behavior, PICA, wandering, etc.) by noting staff's level of experience.

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* 11. Please check all supports provided for persons who require assistance with TRANSPORTATION.

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* 12. If you provide RESIDENTIAL SUPPORTS, please provide the following information.

  Bedroom private or shared Population by Gender Levels/Floors Typical Age range of Residents Typical Staffing Ratio Awake Overnight Staff Available
Across all homes

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* 13. Has your staff participated in training in

  Person-Centered Thinking Person-Centered Planning
Training

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* 14. Is your agency willing to consider developing additional services to meet individual needs?

T