| Please
verify selections and hit "Submit" to complete survey. |
| Name:
(Optional)
|
| Date:
County:
|
| |
| Services
that your child receives |
| 1. (Birth
to 3 years services only) Did your child's teacher/service
coordinator provide services for your child?
-Please
list up to 3 things the teacher/service coordinator did to help
your family:
|
Yes
No
|
| 2.
Were you given a chance to talk about how your child was doing
at least every 3 months? |
Yes
No
|
| 3.
Were you involved in your child's evaluation/testing? |
Yes
No
|
| 4.
Did you have enough personal contact with the person/service
coordinator who helped you get services? |
Yes
No
|
| Outcomes
for families |
| 1.
Did your child work on and finish the lessons written on the
plan (IFSP)? |
Yes
No
|
| 2.
As a parent, did you help in your child's treatment? |
Yes
No
|
| 3.
The services my child is receiving are ... (rate on a scale of 1
being poor and 5 being good) |
1
23
45
|
| 4.The
help my family is receiving is ... (rate on scale of 1 being
poor and 5 being good) |
1
23
45
|
| 5.
I was talked with about how well my child did on his plan. |
Yes
No
|
| 6.
The people who worked with my child seemed to understand our
needs. |
Yes
No
|
| 7.
Were the services started for your child within 3 weeks after
the IFSP plan? |
Yes
No
|
Moving
from one program to another (Transition)
Complete only if
your child is over 3 years of age |
| 1.
Were you given choices for services when your child turned 3
years of age? |
Yes
No
|
| 2.
When my child turned 3 years, he/she qualified for 3 to 5 year
old special education Services. |
Yes
No
|
| 3.
Was your child changed to a 3 to 5 year old program?
-Which Program did he/she move to?
|
Yes
No
|
| 4.
When my child turned 3 years, change was made without stopping
services. |
Yes
No
|
| 5.
Do you think being in the 0-3 year old program helped your
child? |
Yes
No
|
| 6.
What one thing would you change about the program?
|
|
| |
| *The
First Connections Arkansas Infant & Toddler Program is in
compliance with Titles VI and VII of the Civil Rights Act and is
operated, managed, and delivers services without regard to age,
religion, disability, political affiliation, veteran status,
sex, race, color, or national origin.
|
| Comments:
|
| |
|
|
