Form 3 State Systems Grantee Survey

State Systems Grant Program

Survey to Assess Progress Toward Program Objectives

Thank you for participating in our Survey of Autism CARES State Systems grantee survey of progress toward program objectives. We value your participation! Our team at Westat Insight is conducting this brief survey under contract with the Health Resources and Services Administration Maternal and Child Health Bureau as part of the Autism CARES Evaluation. We expect this survey to take 5 to 10 minutes.

This survey seeks to collect information about progress to date in achieving the target 25% increases in the following objectives by the end of the current grant period that includes September 2019 to August 2023.

1. The number of children with or at risk for autism and developmental disabilities (DD) in medically underserved areas receiving family navigator services

2. The number of families of children with or at risk for autism/DD reporting self-efficacy in navigating the system of care and services for autism/DD

3. The number of children with or at risk for autism/DD receiving referrals for both comprehensive developmental evaluations and early intervention services before 3 years of age

4. The number of children with or at risk for autism/DD in medically underserved areas enrolled in community-based services and supports before 3 years of age

5. The percent of primary care, specialty care, and community-based providers implementing care coordination for children with/at risk for autism/DD in targeted medically underserved areas and populations

If you have questions about this survey or how we will use the information you provide, please contact Project Director Katherine Flaherty ([email protected]) or Deputy Project Director Carla Bozzolo ([email protected]).

Date survey completed (mm/day/year): / / /

Let’s start with the first objective and work our way through each one.

1. For the number of children with or at risk for autism/DD in medically underserved areas receiving family navigator services:

1. Do you have a baseline measure that you use in assessing your progress? Y/N ________

   • If yes:

     • What is your baseline measure? _________________________________________

     • What is the source of your baseline measure? ______________________________

     • What is the year of your baseline data? ___________________

2. How many children with or at risk for autism/DD in medically underserved areas are currently receiving family navigator services? _____________

• What was the date that the number above was retrieved? (mm/day/year): / / /

• What percent change does the number above represent from baseline? _____________

• What are the sources of your current data? (For example, hospitals/medical records, private clinicians/medical records, surveys, enrollment records)

_________________________________________________________________________

• How were these sources used to determine a total number?

_________________________________________________________________________

2. For the number of families of children with or at risk for autism/DD reporting self-efficacy in navigating the system of care and services for autism/DD:

1. Do you have a baseline measure that you use in assessing your progress? Y/N ________

   • If yes:

     • What is your baseline measure? _________________________________________

     • What is the source of your baseline measure? ______________________________

     • What is the year of your baseline data? ___________________

2. How many families of children with or at risk for autism/DD in medically underserved areas are currently reporting self-efficacy in navigating the system of care and services for autism/DD? ___________

• What was the date that the number above was retrieved? (mm/day/year): / / /

• What percent change does the number above represent from baseline? _____________

• What are the sources of your current data? (For example, hospitals/medical records, private clinicians/medical records, surveys, enrollment records)

_________________________________________________________________________

3. The number of children with or at risk for autism/DD receiving referrals for both comprehensive developmental evaluations and early intervention services before 3 years of age:

1. Do you have a baseline measure that you use in assessing your progress? Y/N ________

   • If yes:

     • What is your baseline measure? _________________________________________

     • What is the source of your baseline measure? ______________________________

     • What is the year of your baseline data? ___________________

2. How many children with or at risk for autism/DD in medically underserved areas are currently receiving simultaneous provider referrals to both comprehensive developmental screenings and early intervention services before 3 years of age? __________

• What was the date that the number above was retrieved? (mm/day/year): / / /

• What percent change does the number above represent from baseline? _____________

• What are the sources of your current data? (For example, hospitals/medical records, private clinicians/medical records, surveys, enrollment records)

4. For the number of children with or at risk for autism/DD in medically underserved areas enrolled in community-based services and supports before 3 years of age:

1. Do you have a baseline measure that you use in assessing your progress? Y/N ________

   • If yes:

     • What is your baseline measure? _________________________________________

     • What is the source of your baseline measure? ______________________________

     • What is the year of your baseline data? ___________________

2. How many children with or at risk for autism/DD in medically underserved areas are currently enrolled in community-based services and supports before 3 years of age? ___________

• What was the date that the number above was retrieved? (mm/day/year): / / /

• What percent change does the number above represent from baseline? _____________

• What are the sources of your current data? (For example, hospitals/medical records, private clinicians/medical records, surveys, enrollment records)

_________________________________________________________________________

5. The percent of primary care, specialty care, and community-based providers implementing care coordination for children with/at risk for autism/DD in targeted medically underserved areas and populations:

1. Do you have a baseline measure that you use in assessing your progress? Y/N ________

   • If yes:

     • What is your baseline measure? _________________________________________

     • What is the source of your baseline measure? ______________________________

     • What is the year of your baseline data? ___________________

2. How many primary care, specialty care, and community-based providers are currently implementing care coordination for children with/at risk for autism/DD in targeted medically underserved areas and populations: __________

• What was the date that the number above was retrieved? (mm/day/year): / / /

• What percent change does the number above represent from baseline? _____________

• What are the sources of your current data? (For example, hospitals/medical records, private clinicians/medical records, surveys, enrollment records)

_________________________________________________________________________

Finally, is there any other additional information that you would like to share with us?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Thank you again!

4