Arkansas TBI Needs Assessment

for Individuals with a TBI and their Support System

You are asked to complete this survey either because you are an individual with a traumatic brain injury (TBI) or provide some type support for an individual with a TBI.  The information you provide will be used to assess strengths and weaknesses in the Arkansas' responses to individuals with a TBI and to guide the planning for better coordination of services. 

Use the <Tab> key to advance to the next question or next selection. 
Do not use the <Enter> key as that will submit the survey, probably before you are ready.
Click the [Submit Form] button when you are finished.

The survey is anonymous – no identifying information will be associated with any response.

There is no deadline for submitting this survey.  It is an ongoing survey.
If you have completed the survey in the past but your situation has changed,
please feel free to complete the survey again.

   
  Q01.

Who are you?

Individual with traumatic brain injury
Family member of individual with traumatic brain injury.  Please identify your relationship below.
Non-family member.  Please identify your relationship below.
    relationship:
    If you checked family member or non-family member in Q1,
please complete the following questions
on the individual you know with a traumatic brain injury.
  Q02.

Gender?

Male
Female
  Q03.

Current age?

   years
  Q04.

Race?

African American
Caucasian
Hispanic
Asian
Other,  Please identify. 
  Q05.

Highest level of education?

Non-high school graduate
High school graduate
Some college or vocational education
Completed undergraduate or vocational education
Post graduate education
  Q06.

Currently employed?

Yes, full time
Yes, part time
No
  Q07.

Living situation?

Live independently
Live with family member or friend
Live in supported setting with other individuals with TBI.
Live in supported setting with other individuals
  Q08.

Arkansas county of residence?

   

Injury Background
  Q09.

How did injury occur?

Motor vehicle
Recreation,  Please specify activity below
Work,  Please specify activity below
Fall
Firearm
Other,  Please specify below
     
  Q10.

In what year did the injury occur?
  Q11.

Age at the time of the injury?

  Q12.

Were Intensive Care Unit (ICU) services received?

Yes for  (length of stay)
No
Not sure
  Q13.

Were Acute Care services received?

Yes for  (length of stay)
No
Not sure
  Q14.

Were inpatient rehabilitation services received at a hospital or a specialty center?

Yes for (length of stay)
No
Not sure
  Q15.

Were outpatient rehabilitation services received from a hospital or specialty center?

 Yes for (length of stay)
No
Not sure
  Q16.

Which of the following services were received by the person with TBI?  Check all that apply. 

      Supported housing  
      Employment  
      Personal care  
      Household care  
      Speech therapy  
      Occupational therapy  
      Physical therapy  
      Appropriate education  
      Nursing services  
      Recreational opportunities  
      Money management/financial counseling
      Transportation  
      Mental health counseling  
      Substance abuse counseling  
      Family counseling  
      Respite care  
      Medical services  
      Access to information  
      Support groups  
   

  Service coordination

 
   

  Other (please specify) 

  Q17.

Which of the following services were needed by the person with TBI but were not obtained?  Check all that apply.
      Supported housing  
      Employment  
      Personal care  
      Household care  
      Speech therapy  
      Occupational therapy  
      Physical therapy  
      Appropriate education  
      Nursing services  
      Recreational opportunities  
      Money management/financial counseling
      Transportation  
      Mental health counseling  
      Substance abuse counseling  
      Family counseling  
      Respite care  
      Medical services  
      Access to information  
      Support groups  
      Service coordination  
      Other (please specify)   
  Q18.  What barriers were experienced in receiving essential services?  Check all that apply.
      Transportation  
      Inability to pay  
      Lack of insurance  
      Services not located locally  
      Difficulty understanding process or paperwork
      Difficulty with English language
      Lack of support/patient advocacy
      Unaware of services and resources
      Difficulty with enrollment/admissions
      Other,  please specify   
    Injury Resources
  Q19. What do you believe are the most important issues experienced by individuals after a brain injury? 
Please rate each issue from 1 (critically important) to 5 (not important at all)
   



Issue


Critically Important 
1

 


2


Somewhat Important
3

  


4

Not
 Important
at all
5
    Medical Issues/Medications
    Personal Relationships
    Fulfilling Vocation/Employment
    Memory/Cognition
    Attention/Focusing Skills
    Anger Management
    Recreation Options
    Housing Issues
    Transportation Issues
    Feelings of Isolation
    Financial Issues
    Public Awareness of TBI
    School/Educational Issues
    Family stress/needs
  Q20. What do you believe are the top priorities for funding/resources? 
Please rate each issue from 1 (highest priority) to 5 (lowest priority)
   



Activity

Critically Important 
1		  


2
Somewhat Important
3


4		 Not
 Important
at all
5
    Peer support for individuals with TBI
    Peer support for family members
    Medical care resources
    Mental health resources for individuals with TBI
    Mental health resources for family members of individuals with TBI
    Community education events
    Community resource guides
    Research into improving medical outcomes
    Research into improving social outcomes
    Research into improving vocational outcomes
    Research into improving cognitive and/or educational outcomes
    Developing resources in language other than English
    Outpatient care
    Education opportunities
    Public Awareness of TBI
    TBI education for health providers
    TBI education for teachers/educational system
  Q21. What resources have you used from the Brain Injury Association of Arkansas?  Check all that apply.
      Peer support  
      Website  (www.brainassociation.org)  
      Newsletter  
      Brochures  
      Meetings :  
      Conference  
      Referral information  
      None
  Q22. What resources have you used from the schools or other educational agencies?  Check all that apply.
      Website (http://arksped.k12.ar.us/  
      Brochures  
      Meeting with principals and/or teachers  
      Testing  
      Counseling  
      Referral information  
      None
  Q23. What resources have you used from the Disability Rights Center?  Check all that apply.
      Website (www.arkdisabilityrights.org)  
      Brochures  
      Meeting with staff  
      Referral information  
      None
  Q24.

What has been the biggest obstacle(s) since the brain injury?
  Q25.

What has been the biggest help for you since the brain injury?

  Q26.

Are you aware of successful programs elsewhere that might be helpful to replicate in Arkansas? 

Yes
No
    If "Yes," please provide detail:
  Q27.

Please provide suggestions that will improve services for Individuals with TBI and/or their families?

   

Please add any other comments you wish to make in the area to the right.

Thank you for taking time to complete this survey. Your responses will be very helpful in planning for the needs for persons with TBI and their families in Arkansas.

Please click the [Submit] button at the top or press the <Enter> key when you are ready to submit your survey.
Your survey will be sent to Beverly Miller.

Beverly Miller may be contacted at:

Beverly Miller
Center for Health Promotion
Dept. of Pediatrics, UAMS
800 Marshal Street, Slot 512-26
Little Rock, AR 72202

Updated 12/14/07 - 10:45 pm - gary@glowar.com