Arkansas Traumatic Brain Injury Provider Resource Assessment

On-line Entry - Services You Provide
(Q15-Q20 & Q22-Q24)
Please complete and submit the following information:
Use the <Tab> key to move from field to field.
Press the <Enter> key or [Submit Form] button to submit.

   
  The following two items will be used to link correctly with submission of
other sections.		  
Organization Name  
Email  
Section B    
15 Does your organization have programs specifically developed for historically
under-served populations (e.g., children & youth, people 65+, American
Indians, Alaska Natives, Hispanics, African American, and Asians)?		 No
Yes
16 Does your organization provide direct services (e.g., treatment, therapy,
transportation, housing, etc.) for individuals with TBI?		 No
Yes
17 Does your organization engage in Prevention Activities? No
Yes
  If "Yes," which services does it provide? (Check all that apply)  
  Primary prevention of intentional injuries (Shaken Baby Syndrome, violence)  
  Primary prevention of unintentional injuries (falls, occupant protection)  
  Secondary prevention (of disabling conditions)  
  Other (Please specify)  
18 Does your organization provide Acute Medical Services? No
Yes
  If "Yes," which services does it provide? (Check all that apply)  
  Acute Medical care  
  Discharge planning/service coordination  
  Emergency medical care  
  Family education, information and training  
  Family mentoring  
  Pre-hospital transport and treatment  
  Referral to subspecialties  
  Screening, identification and provision of discharge protocols at all levels of
     TBI (mild, moderate, severe)		  
  Substance abuse screening  
  Trauma systems  
  Other (Please specify)  
19 Does your organization provide Education Services? No
Yes
  If "Yes," which services does it provide? (Check all that apply)  
  Advocacy (Family/Child)  
  Charter/private school  
  Early intervention/preschool  
  Education (Kindergarten - 12th grade)  
  Health related services (i.e., OT, PT, Speech, etc.)  
  Higher education  
  Special education (including all services outlined in IDEA)  
  Transitional services  
  Other (Please specify)  
20 Does your organization provide Employment Services? No
Yes
  If "Yes," which services does it provide? (Check all that apply)  
  Advocacy (self/family)  
  Assistive technology  
  Career counseling/guidance  
  Job accommodations  
  Job coaching  
  Job development  
  Job placement  
  Pre-vocational services  
  Special skills training (computer, data processing)  
  Supported employment  
  Vocational evaluation  
  Work adjustment  
  Work support  
  Other (Please specify)

 

  
21 Does your organization fund or provide Rehabilitation Services?
(Because this is such a large item, it has been removed and made a
separate entry.)		  
22 Does your organization fund Long-Term Community Support services? No
Yes
  If "Yes," which services does it provide? (Check all that apply)  
  Advocacy (self and community)  
  Assistive Technology  
  Case Management/Service Coordination  
  Chronic Neurobehavioral Treatment  
  Clubhouse  
  Coma Care  
  Day Program  
  Durable Medical Equipment/Supplies  
  Family Support, Education & Training  
  Home Care/Home Support  
  Housing (Assessible/Affordable)  
  Housing (Modification)  
  Housing (Supervised/Supported)  
  Independent Living Services  
  Information/Resources  
  Legal Services  
  Mental Health Services  
  Nursing Care  
  Peer Support  
  Personal Assistance/Attendant Services  
  Primary Care Medical Services  
  Recreation/Social Programs  
  Respite Care  
  Skilled Nursing Care  
  Substance Abuse Treatment  
  Transitional Living Services  
  Transportation (Taxi Voucher, Medicaid)  
  Other (Please specify)  
23 Please indicate by age group how many individuals with TBI received the
following services from January 1, 2007 to December 31, 2007.

 

Service

 Infants
(0-3)		 Children
(4-12)		 Adolescents
(13-17)		 Adults
(18-64)		 Older Adults
(65+)
Applied Rec'd Applied Rec'd Applied Rec'd Applied Rec'd Applied Rec'd
Prevention
Acute Medical
Rehabilitation
Education
Employment
Legal
Long Term
Community
Support
Other
  Please explain any entries in the Other fields
 
24 Does your organization provide financial resources for individuals with TBI? No
Yes
  If "Yes," in what areas is financial assistance available (Check all that apply)  
  Shelter costs (food, mortgage, rent, utilities, etc.)  
  Assistive technology  
  Home Care/Home support  
  Personal attendant services  
  Medical equipment/supplies  
  Respite care  
  Transportation  
  Other (Please specify)  

Updated 6/27/08 10:30 pm - glowar@sbcglobal.net