Service Providers and Case Workers

Governor John A. Kitzhaber, M.D., formed The Governor's Task Force on Traumatic Brain Injury with Executive Order NO. 01-02. One of the charges to the Task Force is to

The survey has four sections. Section I asks for general information about your organization and information on the current services it is providing for survivors of BI. Information from Section I will be used to supplement information in the Oregon Brain Injury Resource Directory database (http://www.tr.wou.edu/tbi/tbires/Agencyse.htm ) which is used by persons with brain injury , their family members, public and private service providers, and other organizations looking for information and assistance. Section IV asks for your opinion about the needs and gaps in the system of services for survivors. This section provides critical information that will aid the Governor

In additional, we are asking for your help by forwarding a request to participate in survey to others who may be interested. In addition to being a provider, if you are a person with brain injury or family member, please fill out the survey for persons with brain injury, their families at Survivor and Family Members Questionnaire.

We thank you in advance for taking the time to complete this survey. Your responses will help the Task Force formulate recommendations that reflect the knowledge and experience of service providers; and by sending information on your organization to OBIRN, you will add to resource information that can be made available to brain injury survivors, family members and professionals serving them. We do appreciate all of your input.

Service Provider Survey

NOTE: Throughout this survey, we will use the abbreviations BI for Brain Injury as defined in ORS 411-065-0005 as


Name of person completing this questionnaire:

Phone number:Email:


SECTION I: General Information/Information for Oregon Brain Injury Resource Network (OBIRN) Resource Database
1. Organization Name:
2. Address:
3. Phone Number:
4. Fax Number:
5. Contact's Name and Position:
6. Contact's Phone Number:
7. Contact's Email Address:
8. Internet URL:
9. Hours Open:
10. Is your organization affiliated with a hospital?
Yes: (If yes, please give us the name of the hospital) No


11. What criteria must a survivor of BI meet to receive services from your organization? (Please check ALL that apply.)

Residency in Oregon
US Citizenship
Physical Condition
Minimum Age of
Maximum Age of
Other (Please describe)
12a. Is your organization: Private, For Profit Nonprofit Public

12b. Does your organization have programs specifically developed for historically under-served populations (e.g., Children, Older Adults, Native Americans, Hispanics, African Americans, Asians)?

Yes No

12c. Do you have bilingual staff?

Yes No

13. Does your organization employ persons with special training and experience in serving persons with brain injury. Please explain. Yes No
14. What county or counties does your organization serve within Oregon?
Statewide or all selected counties, please list below
15. Please check the setting where you most often provide services:

16. What is the average age of consumers most typically served by your organization?

What range of ages do you see?

17. Have you used the Oregon Brain Injury Resource Network ?
Yes (Please check all that apply) No (if No, please see http://www.tr.wou.edu/tbi/)

Phone Online Comments

 Section II. Brain Injury Services
18. What is the BI program emphasis for your organization? (Please check all which apply.)
a. Acute rehabilitation
b. Coma management
c. Day treatment
d. Education
e. In-home service
f. Independent living
g. Long-term residential
h. Physical medicine and rehabilitation
i. Social/emotional/behavioral adjustment
j. Substance abuse
k. Transitional living
l. Vocational rehabilitation
m. Other (Please specify.)
n. Not applicable
19. Indicate from which entities your organization receives referrals for services related to BI (Check all that apply.)
a. County Health Department
b. Vocational Rehabilitation Services (Voc Rehab)
c. Other State Agency (not Vocational Rehabilitation)
d. Self-referrals by survivor or family member/care-giver
e. Hospitals
f. Schools
g. Professionals (e.g., physician, counselor, etc.)
h. Other (Please specify.)
i. Not applicable

Section III: Service Matrix

20. Organizational Categories

Please place your organization into one of the following categories by checking the appropriate letter. If none of these categories is appropriate for your organization, please use the "Other" category to describe your organization.

a. Acute Hospital Programs and Services: The primary identifier in this category is the availability of acute medical care.
b. Specialty Hospital Programs and Services: Included in this category are hospitals serving special populations. Areas of specialization include rehabilitation hospitals, pediatric intermediate care facilities, long-term acute care, and psychiatric care.
c. Nursing Home/Extended Care Facilities Specialty Programs: Nursing homes having specialty programs for head injured people.
d. Individual Professional Services: Included in this category are physicians, therapists, nurse case managers, counselors, psychologists, and many others.
e. Home and Community-Based Service Delivery Programs: Organizations providing a variety of services; the primary identifier in this category is that the programs are non-residential and not affiliated with hospitals.
f. Community Residential Programs: Organizations providing nonmedical residential care.
g. County Health Agencies.
h. Other: (Please describe.)

21. Service Categories

Please check all services provided by your organization. If you provide a service not listed below, please use the "Other" category to describe that service.

a. Day Treatment: Social/recreational programming, support groups, cognitive rehabilitation, respite care (nonresidential), independent living training.
b. Case Management: Referral, school reintegration, social work, advocacy.
c. Mental Health: Neuropsychology, psychiatric, psychological, crisis intervention, counseling.
d. Medical Rehabilitation: Physical therapy, occupational therapy, speech therapy, respiratory, nursing, physicalist, physician, ventilator.
e. Substance Abuse: Substance abuse detoxification
f. Vocational/Educational: Academic, employment, driver education, vocational evaluation/training.
g. County Health Agencies.
h. Other: (Please describe.)

   Section IV. Service Needs/Gaps

In this section, we would like you to provide your insights on needs and service gaps within your organization and the community. This section provides critical information that will aid the Governor

22. How well are services coordinated for people who need services from more than one agency? Select the number below that best describes the inter-service coordination for people with BI. "1" means "Services not coordinated well from one agency to another. " "5" means "Very good inter-agency coordination."

 1 2 3 4 5

23. What are the most critical areas where such coordination is needed? What would make it better?

24.What are the most important obstacles your organization faces in delivering services to persons with brain injury and/or their families?

25. What services to persons with BI and their families would you or your organization like to provide that you cannot provide?


26. Do you think that there are significant gaps in services for persons with BI and their families in Oregon?


26a. If yes, which do you consider to be the most significant?

27a. Is there an effective network of services for survivors of BI in your community?


27b. (If no, please describe why you feel it is ineffective.)

28a. Does your organization have any formal inter-agency agreements with another agency or organization that serves survivors of BI?

YES (If yes, please list the organization(s) and the purpose and/or nature of the agreement(s).)

NO (if no, please indicate if you think such a formal agreement would be helpful)

28b. Response to Yes or No above:

29. What is your most critical need or requirements at this time?


30. Please add any other comments on matters not covered elsewhere in this questionnaire that you think would be helpful in improving services for persons with BI or their families? (Please provide below.)


 If you would like a copy of your survey, please print this survey before clicking submit button.


The Governor's Task Force on Traumatic Brain Injury is supported by grant number 1 H21MC00043-01 from the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
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