LCSC Social Work Student Intern

Survey of Medical Providers  

     You are invited to participate in a survey to gather feedback from family practice and pediatric physicians, nurse practitioners, and nurses. The purpose of the study is to identify issues related to communication and collaboration as well as other barriers between the Infant Toddler Program and medical personnel that is hindering referrals to the Infant Toddler Program.

     Your participation in this survey is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. Your survey responses will be strictly anonymous and data from this research will be reported in the aggregate. Once you complete the survey and submit it, anonymous data will be forwarded to the evaluators. This survey should take approximately 5-10 minutes to complete.

     Please complete each question to the best of your ability. If you have any questions or require assistance to complete this survey please feel free to contact Jennifer Boisen at jlboisen@lcwarriormail.com or at 208-798-4110. By taking the time to complete and submit the survey, you are acknowledging acceptance of the informed consent provided. If you have any questions regarding this study feel free to contact Dr. Brian L. Christenson at (208) 792-2476 or the LCSC Institutional Review Board at 208-792-2461.    

Please Begin By Answering the Questions Below to the Best of Your Ability  

1.  AT WHICH MEDICAL FACILITY DO YOU WORK? (Please check or write in)

Clearwater Valley Hospital

Gritman Medical Center

Lewiston Medical Center

Moscow Family Medicine

St. Joseph’s Regional Medical Center 

St. Mary’s Hospital and Clinic

Syringa Hospital & Clinics

Valley Medical Center

Other (Please write in)    

2. What position do you hold?  (please check)          

Pediatric physician    Family practice physician    Nurse practitioner   Nurse                 

3. Please Estimate the peRcentage of Children, ages Birth to three, Served By your practice? (Please write in):

4. TO What Extent are you familiar with the infant toddler program? (Please check)

Not familiar    Slightly familiar    Familiar    Mostly familiar   Very familiar  

If not familiar, scroll to the end of the survey and submit 

5. How did you first learn About the idaho infant toddler program?

(Please check or write in)

Brochure            Internet            Newsletter            Parents            Physician Packets            Other medical personnel     

Other community contacts              Other (Please write in):      

6. In the year 2007, How many children, birth to 3, have you referred to the infant toddler program? (Please check)

0       1-3      4-7    8-11    12+   

7. The communication between your practice and the infant toddler program is open and positive (please check)

1                   2                  3                  4                  5              

Almost never        Sometimes                       Often                   Very frequently       Almost always  

8. DO YOU RECEIVE CHILD EVALUATIONS AND PROGRESS NOTES FROM THE INFANT TODDLER PROGRAM (PLEASE CHECK)

Yes     No

If yes, do you find child evaluations and progress notes helpful in your practice?

(Please check)

1                  2                  3                  4                  5                             

Almost never        Sometimes                     Often                      Very frequently     Almost always   

9. Do you have any suggestions on how to improve communication Between the infant toddler program and your practice?

(please write in)

10.  HOW WOULD YOU RATE THE EFFECTIVENESS OF THE INFANT TODDLER PROGRAM IN SUPPORTING YOUNG CHILDREN WITH DISABILITIES AND THEIR FAMILIES? (PLEASE CHECK AND WRITE IN)

1                         2                         3                          4                        5

never                    sometimes                 effective                    frequently                 always               

effective                effective                                                        effective                 effective

If never effective or sometimes effective what changes would you suggest to improve the effectiveness of the Infant Toddler Program? (Please write in)

11. The relationship between the infant toddler program and YOUR MEDICAL practice is characterized by mutual trust and respect

(Please check)

1               2               3                 4              5   

 Never               Sometimes                  Often                   Frequently              Always

12. To what extent do you know the process to refer Patients to the infant toddler program? (Please check)

I do not know how to refer  

I vaguely know how to refer  

I somewhat know how to refer

I mostly know how to refer

I know how to refer

13. Are there barriers to referring a child/family to the infant toddler program

(Please Write in)

Please feel free to provide additional comments: