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Assessing Community Resources
For purposes of this survey, "community" is defined as the area covered by a supervisory union. If your community uses a different definition, please let us know so that we may maintain consistency of survey results.
1. Has your community been designated as a medically undeserved area (MUA), medically underserved population (MUP), or health professional shortage area (HPSA)? (If you are not sure, check with your local health department district director.)
MUA, when ________________
MUP, when ________________
HPSA, when _______________
2. Which primary care facilities are in (or near) your community? Check all that apply.
__ 1-Health care
__ 2-Community health
__ 3-Rural health clinic
__ 4-Private provider or group practice
__ 5-General dentist
__ 6-Pediatric dentist
__ 7-School-based clinic
3. Is there a neonatal intensive care unit in your community?
__ 1-Yes
__ 2-No3a. If no, how many miles away is the closest facility? _______________
4. Is there a pediatric intensive care unit in your community?
__ 1-Yes
__ 2-No4a. If no, how many miles away is the closest facility? _______________
5. Is there a hospital in your community?
__ 1-Yes
__ 2-No5a. If yes, what level of service does it provide?
__ 1-Primary
__ 2-Secondary
__ 3-Tertiary5b. Name and location of nearest hospital: __________________________________
5c. Which hospital is primarily used by members of your community? ____________________________________________________________________
6. Are there dental specialists for children and adolescents in your community?
__ 1-Yes
__ 2-No
7. Are there health department programs in your community for children with special needs?
__ 1-Yes
__ 2-No7a. If no, how far do families with children with special needs have to travel to get services? _______________________________________________________________
8. Is there a community mental health center in your community?
__ 1-Yes
__ 2-No8a. If yes, is there a waiting list for children and adolescents to be seen by providers?
__ 1-Yes, ______ days; ______ weeks; ______ months
__ 2-No8b. If there is no center, how many miles away is the nearest facility? _______________
9. Is there an alcohol and drug treatment program in your community?
__ 1-Yes
__ 2-No9a. If yes, is there a waiting list for children and adolescents to be seen by providers?
__ 1-No
__ 2-Yes, ______ days; ______ weeks; ______ months9b. If there is no program, how many miles away is the nearest facility? _______________
10. Is there an emergency medical services system for children in your community?
__ 1-Yes
If yes, answer the following:
__ Y __ N 10a. Are all geographic areas covered?
__ Y __ N 10b. Is the service adequate to handle common emergencies of children?
__ Y __ N 10c. Is "911" emergency access calling available to all areas?
__ Y __ N 10d. Does the local ambulance service carry appropriate pediatric equipment?
__ Y __ N 10e. Have local ambulance personnel received specialized training in pediatric emergencies within the past 2 years?__ 2-No
11. Which of the following health promotion and education programs are available in the community? Please identify where they take place and who provides them.
| PROGRAM | YES OR NO | WHERE; WHO PROVIDES? |
| a. Childbirth classes | ||
| b. Infant and child care classes | ||
| c. Parenting education and nurturing program | ||
| d. Car seat distribution | ||
| e. Nutrition | ||
| f. Injury prevention | ||
| g. Smoke detector distribution | ||
| h. Poison control | ||
| i. STD education and prevention | ||
| j. HIV/AIDS education and prevention | ||
| k. Substance abuse education and prevention | ||
| l. Teen pregnancy education and prevention | ||
| m. Obesity prevention/management | ||
| j. Other (describe) |
12. What health education or health promotion programs do you provide to the minority population(s) in your community?
13. Which of the following services are available for preschool (ages 0-5) children in the community? Please identify who provides the services.
| PROGRAM | YES OR NO | WHERE; WHO PROVIDES? |
| a. Mental health screening and care | ||
| b. Home visiting | ||
| c. Social service referrals | ||
| d. Adequate child care | ||
| e. HeadStart | ||
| f. Parent-child centers | ||
| g. Family, infant, toddler program | ||
| h. Child protection team | ||
| i. Healthy babies | ||
| j. Success by Six | ||
| k. Developmental screening |
14. Please identify which of the following services are available for school-age children (ages 5-11) and youth (ages 12-18) and who provides these services for the community.
| PROGRAM | YES OR NO | WHO PROVIDES? | ||
| 5-11 | 12-18 | 5-11 | 12-18 | |
| a. Mental health screening and care | ||||
| b. Alcohol and drug counseling | ||||
| c. Family planning and reproductive health services | ||||
| d. Home visiting e. Social service referral | ||||
| f. Adequate child and after-school care | ||||
| g. Child protection team | ||||
| h. Success Beyond Six | ||||
| i. Individual educational program health-related project | ||||
| j. Dental health screening and referral | ||||
| k. Fluoride mouth rinse program | ||||
| l. Dental sealant program | ||||
| m. Other (describe) | ||||
15. How many child care and after-school care programs are there in the community that are:
__ 1-State licensed
__ 2-State registered
__ 3-Accredited by the National Association for the Education of Young Children
16. Is there any system in your community, either through an individual or an agency, which coordinates health education and social services for families?
__ 1-No
__ 2-Yes
If yes, please describe:
17. Is there a way for families to know that the services their children and adolescents are receiving are coordinated among providers?
__ 1-No
__ 2-Yes
If yes, please describe:
18. Is there a person or place for families to learn about the services available in the community for their children and adolescents?
__ 1-No
__ 2-Yes
If yes, please describe:
19. Are there any community coalitions or task forces that focus on services for children or adolescents?
__ 1-No
__ 2-Yes
If yes, please describe:
20. How would you rate the level of integration among health, education, and social service providers in the community?
__ 1-None
__ 2-Poor
__ 3-Adequate
__ 4-Good
__ 5-Excellent
21. Who participated in gathering the information for this survey?
