Please return completed survey to:

1. Agency or Facility:______________________________________________

Contact Person__________________________________________________

Title of Contact Person____________________________________________

Street Address:___________________________________________________

City______________ State___________ Zip Code_______________

Phone Number, including area code (_____) _____________________

Fax Number, including area code     (_____)______________________

Email Address:____________________________________________

__ Yes. Please complete the rest of this survey.

__ No. Stop here. Please return survey to address listed above.

3. What agency or person is responsible for assuring that a child who has a confirmed
hearing loss enrolls in an early intervention program? Check all that apply.

__ State Department of Public Health
__ Parents
__ Part C (Part H)
__ Child Find
__ School for the Deaf
__ Another state agency, please describe_________________________
__ Other, please describe.____________________________________
__ No system is in place

4. Who refers children to your intervention program? Check all that apply.

__ Physician
__ Public Health Nurse
__ Audiologist
__ Parents of child
__ Service Coordinator (Part C, Part H)
__ Speech-Language Pathologist
__ Other, e.g., grandparents, neighbors_______________________________
__ Other, Please specify.__________________________________________

5. Which of the following best describes the majority of communities you serve?

__ Communities are drawn from across the state.
__ Communities are drawn from a county or a region.
__ Communities are drawn from a single city or town.

6. Are you aware of the hospital-based universal newborn hearing screening programs in the community/communities you serve?

8. Where do you provide early intervention services? Check all that apply.

__ In Home
__ In Clinic
__ In School
__ Other, please describe_____________________________________

9. On average, how frequently do you provide early intervention services?

__ Weekly
__ Two times each month
__ Monthly
__ Other, please describe__________________________________________

10. Please indicate the topics you discuss with the audiologist(s) who manage children enrolled in the early intervention program. Check all that apply.

__ Audiological Reports
__ Choice of communication/language method
__ Hearing aid/cochlear implant fittings and settings
__ Assistive listening devices
__ Referral for additional rehabilitation services
__ Other, please describe__________________________________

 11. List the funding sources that pay for intervention services for children who are deaf or hard of hearing in your program.

12. What intervention approach(es) do you provide for families? Check all that apply.

__ Auditory Verbal
__ Auditory Oral
__ Total Communication
__ Simultaneous Communication
__ Cued Speech
__ American Sign Language
__ Other_______________________________________

13. Which of the following approaches do you incorporate into your intervention program.
Check all that apply.

__ Direct service is provided to families.
__ Direct service is provided to child.
__ Assessment of child’s progress is done by professional.
__ Assessment of child’s progress is done by parent.
__ Children receive services in a group
__ Parents receive counseling in a group.

14. What of the following do you incorporate into your intervention program? Check all that apply.

Psychosocial Counseling, including:

__Grieving Stages
__Family Systems
__Bonding

Information Counseling addressing:

__Child Development
__Educational programs
__Amplification
__Communication Methodology
__Parent support groups
__Deaf Culture
__Social skill development
__Emotional skill development

15. Does your program refer families to local and/or national parent support groups?

__ Yes

__ No

16. Does your program involve parents of children who are deaf/hard of hearing in any of the following ways? Check all that apply.

__ Parents are on staff and paid by the program
__ð Parents are program or policy consultants and paid by the program
__ Parents are members of boards of trustees
__ Parents are members of committees hiring new staff
__ Parents serve as co-trainers for preservice or inservice sessions
__ Parents are reviewers of written material
__ Parents serve as mentors for other families
__ Other, please specify_____________________

17. Does your program offer activities for parents? Check all that apply.

__ Parent support groups
__ Father groups
__ Mother groups
__ Parent-to-parent connections
__ Parent satisfaction surveys
__ Newsletters for parents
__ Other, please specify___________________________________________

Check all that apply.

__ Paraprofessionals provide direct services to families.
__ Professionals with Bachelor’s degrees provide direct services to families.
__ Professionals with Master’s degrees provide direct services to families.
__ Other___________________________________________________

19. What pre-service training programs have trained the primary interventionists on your staff? Check all that apply.

__ Education of the Deaf/Hard of Hearing
__ Speech/Language Pathology
__ Audiology
__ Early Childhood Special Education
ð Other (please explain)__________________________________

ð Medical Specialists
ð Occupational Therapist/ Physical Therapists
ð Psychologists
ð Social Workers
ð Parent advocates
ð Deaf/ hard-of-hearing role models/mentors/sign language instructors

 22. Which populations does the early intervention program serve?

Indicate ratio (e.g., 2/21)

Dual sensory impairment (deaf-blind) ________________________

Additional physical disabilities ________________________

Cognitive Disability ________________________

24. What communication methods/strategies are used in the program?

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