Questionnaire for Pediatricians Serving the Special Needs Population

2-1-1 First Call For Help needs your assistance in finding pediatricians and medical professionals in our immediate community that serve children (birth-22) with special needs and developmental disabilities (e.g. Autism, Cerebral Palsy, visual or hearing impairments). The goal is to create an information and referral database for parents and providers in Broward County who require specialized accommodations and treatments for a child with special needs. If you choose to complete this survey, you must also input your name, title, and principle site address in order to be included in this information and referral database, which is at no charge. By taking a moment to complete this survey, you will be helping to identify appropriate referrals for the special needs community in Broward County. Please return survey by fax or mail to below address. We sincerely thank you for your time and consideration.

Physician's Name:

__________________ ______________________ ___________

First, Last, Title

Please list your principal office in Broward County:

__________________________________________

Phone: ____________________________________

1. What is your area of specialization?

[] Developmental Pediatrician

[] Family Practitioner

[] Children and Adolescents

[] Other Pediatrician Specialization (please specify) ___________________

Insurances accepted: [] Medicaid-Waiver [] Medicaid / Medicare [] Private Insurances [] Offer Sliding Scale Fee

2. Which age group(s) do you see consistently in your practice? (Check all that apply)

[] Newborns / Infants with Disabilities

[] Children with Disabilities

[] Adolescents / Youth with Disabilities

[] Adults (please specify ages) ______________

3. Approximately what percentage of your practice, in a 12-month period, consisted of serving

children with special (health care) needs? _____%

4. Please identify any specialization / trainings that you or your medical team has:_____________

[] Autism [] Cerebral Palsy [] Visual Impairments [] Hearing Impairments [] Mental Retardation

Other(s):______________________________________________________________________

Accessibility

5. Are you willing to reasonably extend a scheduled appointment (or currently do so) when seeing

a child with special needs at your office?

[ Yes ] [ No ]

Additional Comments:__________________________________________________________

6. Is the patient site fully accessible to the disabled population?

[ Yes ] [ No ]

Additional Comments:__________________________________________________________

7. Does your facility permit the parent or guardian of the child to attend, on-site, all appropriate

medical procedures (including hospitalizations)?

[ Yes ] [ No ]

Additional Comments:__________________________________________________________

Coordination

8. Would your office consider contacting the school regarding a child’shealth and education

needs, as part of care coordination (or do you currently perform this type of communication)?

[ Yes ] [ No ]

Additional Comments:___________________________________________________________

9. Are you knowledgeable about resources (direct or indirect: e.g., federal, state, local,

foundations, clubs, non-governmental agencies) available to families of special needs children?