Arkansas Traumatic Brain Injury Provider Resource Assessment

On-line Entry - Additional Organization Information
Q1-Q14
Please complete and submit the following information:
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  The following two items will be used to link correctly with submission of
other sections.		  
Organization Name  
Email  
Section A    
1 Does your organization provide services for individuals or families who have
experienced traumatic brain injury (TBI)?		 No
Yes
2 Through which agency is your organization accredited?  
  Commission on Accreditation of Rehabilitation Facilities  
  Joint Commission on Accreditation of Hospital Organizations  
  American College of Surgeons-Trauma Center: Level  
  None  
  Other (Please specify)  
3 In which county(ies) in Arkansas does your organization offer services for
individuals with TBI? (Select counties below)
 
Arkansas
Ashley
Baxter
Benton
Boone
Bradley
Calhoun
Carroll
Chicot
Clark
Clay
Cleburne
Cleveland
Columbia
Conway
Craighead
Crawford
Crittenden
Cross
Dallas
Desha
Drew
Faulkner
Franklin
Fulton 		Garland
Grant
Greene
Hempstead
Hot Springs
Howard
Independence
Izard
Jackson
Jefferson
Johnson
Lafayette
Lawrence
Lee
Lincoln
Little River
Logan
Lonoke
Madison
Marion
Miller
Mississippi
Monroe
Montgomery
Nevada 		Newton
Ouachita
Perry
Phillips
Pike
Poinsett
Polk
Pope
Prairie
Pulaski
Randolph
Saline
Scott
Searcy
Sebastian
Sevier
Sharp
St. Francis
Stone
Union
Van Buren
Washington
White
Woodruff
Yell
 
4 Estimate what percentage of your payments from clients comes from each
of the following sources:		  
  % Medicaid  
  % Medicare  
  % Private Insurance  
  % Other (Please specify sources)  
5 What was the total number of individuals served by your organization?
  Between what dates? From   to   (Specify own dates)  
6 Using the above timeframe, what was the total number of individuals served
by your organization who had a primary diagnosis of TBI ?
7 Indicate how referrals for services related to TBI are received in your
program. (Check all that apply)		  
  Resource line (e.g. 211 system, 1-800#)  
  Voluntary registry  
  Reporting regulation/mandated registry  
  From acute care hospital  
  From rehabilitation facility  
  From judicial system  
  From the State's Office of Vocational Rehabilitation  
  From other State agencies (not VR)  
  From Protection & Advocacy  
  From Brain Injury Association or other non-profit organization  
  Professional Practitioners (counselors, physicians, etc.)  
  Self Referral  
  Other (Pease specify)  
  No system identified  
8 Using the following categories, indicate the total number of individuals
with TBI served by your organization
From   To  . (Specify own dates)		  
  Race:  
    African American  
    Asian  
    Hispanic  
    American Indian/Alaska Native (List tribal affiliation, if available)
               		 
    Caucasian  
  Other (Please specify)  
  Gender:  
  Female  
  Male  
9 How soon after injuries are people typically referred for services?  
  % Within 30 days  
  % 1 to 6 months  
  % 7 to 12 months  
  % 1 to 3 years  
  % 4 to 6 years  
  % 6 years or more  
10 Does your organization have designated staff specifically assigned to work
on issues related to TBI?		 No
Yes
  If "Yes," please indicate all issues that are addressed. (Check all that apply)  
  Alcohol/drug addiction  
  Crisis situations  
  Mental health counseling (individual and family)  
  Family support  
  Employment  
  Housing  
  Transportation  
  Education  
  Assistive technology  
  Other (Please specify)  
11 Identify the total number of staff in your organization.
12 Identify the total number of staff in your organization who work primarily with
individuals with TBI more that 50% of time
13 Estimate the number of hours spent per year in continuing education and
training specific to TBI by staff who serve individuals with TBI
(e.g., conferences, workshops, etc.).
  Hours per year of education/training specific to TBI
14 Does your organization offer educational and/or training programs on TBI? No
Yes
  If "Yes," for which groups are education/training available? (Check all that apply)  
  Individuals with TBI  
  Family/significant others  
  Own staff  
  TBI Statewide Advisory Board/Council  
  Health professionals/rehabilitation providers  
  Law enforcement/criminal justice  
  Educators/teachers  
  Other (Please specify)  
  If "Yes," what type of training is provided or funded?  
  Orientation of new employees  
  In-services  
  Conferences  
  Consulting  
  Other Professional Development  
  TBI Statewide Advisory Board  
  Other (Please specify)  

Updated 07/05/08 3:00 pm - glowar@sbcglobal.net