Arkansas Traumatic Brain Injury Provider Resource Assessment

On-line Entry - Needs/Gaps in Services
(Q25-Q30)
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 C    
25 Does a representative from your organization participate on the TBI Advisory Board
or Task Force?		 No
Yes
26 Is there TBI representation on any of your organization's task forces or advisory boards?

(N/A means your organizations does not have task forces/advisory boards)		 No
Yes
N/A
  If "Yes,", please describe
 
27 Does your organization have any formal inter-agency agreements with another agency
or organization that serves individuals with traumatic brain injury?		 No
Yes
  If "Yes," please list organizations
 
28 Are there gaps in TBI related services in your organization? No
Yes
If "Yes," please describe
29 Are there existing TBI services that need to be expanded in your organization? No
Yes
  If "Yes," please describe
 
30 Are there other significant gaps in TBI services in Arkansas? No
Yes
  If "Yes," please describe
 
31 Please include any other comments you wish for us to receive.
 
Reminder: Please mail a copy of any relevant printed information about your organization to:

Arkansas Department of Health TBI Program
4815 W Markham, Slot H10
Little Rock, AR 72205-3867

  

updated 6/24/08 10:30 pm - glowar@sbcglobal.net