Arkansas Early Intervention Program (Birth - 3 years) Family Outcomes Survey

PURPOSE: Family Survey data helps our program ensure that we are meeting the needs of families and helps us with program improvement planning. Your time and answers are greatly appreciated!

DIRECTIONS: Please select the answer that best describes your family right now. You will notice that the responses include the word “we.” This refers to your family. It’s okay if you are answering just for yourself (your own opinion or experience) or as a family with a shared opinion or experiences. You are rating your family's experience in the early intervention program as a whole, from referral to transition or exit.

If you have questions or need assistance, please call 501-682-8699.

**The following information is collected for reporting purposes only.

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* County of Residence:

Question Title

* Race: You may select more than one.

American Indian or Alaskan Native -A person having origins in any of the original
peoples of North and South America (including Central America) who maintains cultural
identification through tribal affiliation or community recognition.

Asian - A person having origins in any of the original peoples of the Far East, Southeast
Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Pacific Islander - A person whose origins are the original peoples of Polynesia,
Micronesia, and Melanesia. Polynesia includes Hawaii (Native Hawaiian), Samoa
(Samoan), American Samoa (Samoan), Tokelau (Tokelauan), Tahiti (Tahitian), and
Tonga (Tongan).

Black - A person having origins in any of the black racial groups of Africa.

White - A person having origins in any of the original peoples of Europe, North Africa, or
the Middle East.

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* Hispanic or Latino Ethnicity: A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

Yes

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* What type(s) of early intervention service does your child and family receive? May choose more than one.

early intervention services are listed on your IFSP

Speech therapy

Physical therapy

Occupational therapy

Developmental therapy

Other service

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* Who provides your Early Intervention Service(s)?

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* My service coordinator's name is ___________.

Your service coordinator schedules your IFSP team meetings. Your service coordinator's name is listed on your IFSP.

Arkansas Early Intervention Program (Birth - 3 years) Family Outcomes Survey

Question Title

* County of Residence:

Question Title

* Race: You may select more than one.

Question Title

* Hispanic or Latino Ethnicity: A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

Question Title

* What type(s) of early intervention service does your child and family receive? May choose more than one.early intervention services are listed on your IFSP

Question Title

* Who provides your Early Intervention Service(s)?

Question Title

* My service coordinator's name is ___________.Your service coordinator schedules your IFSP team meetings. Your service coordinator's name is listed on your IFSP.

* What type(s) of early intervention service does your child and family receive? May choose more than one.

early intervention services are listed on your IFSP

* My service coordinator's name is ___________.

Your service coordinator schedules your IFSP team meetings. Your service coordinator's name is listed on your IFSP.