Division of Community Family Health & Equity

Department of Health

Three Capitol Hill

Providence, RI 02908-5097

(401) 222-5960

TTY: 771

Division of Community Family Health & Equity

Maternal & Child Health Program

Block Grant Community Input

Community Member Survey

The Division of Community Family Health & Equity (DCFHE) is interested in your input to the next Maternal and Child Health (MCH) Plan. The DCFHE creates programs and activities that help with a person’s needs across their lifetime, or life cycle, that affects their health. A person’s health is affected by many things across their life cycle such as family, school, jobs, money, stress, and housing among other things. The goal of the MCH Program is to deal with all of these issues and improve the health of everyone in the state of Rhode Island.

Please take a few minutes to give feedback on strengths and areas of opportunity on existing state MCH program activities.

1. What is your PRIMARY role in filling out the survey? Please chooseONLY ONE.

1. A member of advisory council or coalition
2. Community service provider
3. Consumer of local health services and programs for pregnant women, infants, children or youth
4. Elected official
5. Health care professional
6. Parent/guardian
7. State health department employee (Rhode Island Department of Health)
8. Other state agency employee
9. Other (please specify below)

1. If your primary role in filling out this survey is as a parent/guardian, is your child age 0 – 21?

1. Yesb. Noc. N/A

1. If your primary role in filling out this survey is as a parent/guardian, are you the parent/guardian of a child with special health care needs (any age)?

1. Yesb. Noc. N/A

1. What COUNTY/CITY do you LIVE in?
2. Bristol County
3. Kent County
4. Newport County
5. Providence County
6. Washington County

City:

For each of the following populations, please CHOOSE YOUR TOP 5 health concerns you feel are most important:

1. Major Health Concerns for Reproductive Age Women (15 - 44 years of age)

1. N/A, I have no interest and/or involvement with this population.
2. Behavioral and mental health
3. Birth spacing
4. Chronic conditions (diabetes, high blood pressure, asthma, etc.)
5. Healthy relationships
6. Health screening and preventive behaviors
7. Obesity
8. Oral health
9. Preconception health and counseling
10. Sexual behaviors (preventing sexually transmitted infections (STIs), knowledge of contraception and effective use, etc.)
11. Tobacco, alcohol, other substance use
12. Wellness (healthy diet, nutrition, physical activity, etc.)
13. Other (please specify below)

1. Major Health Concerns for Pregnant Adolescents and Women

1. N/A, I have no interest and/or involvement with this population.
2. Behavioral and mental health
3. Birth spacing
4. Breastfeeding, education and support
5. Child birth and parenting education
6. Chronic conditions (diabetes, high blood pressure, asthma, etc.)
7. Early prenatal care
8. Genetic testing and counseling
9. Health screening and preventive behaviors
10. Healthy relationships
11. Obesity
12. Oral health
13. Prenatal/Postpartum care and education
14. Sexual behaviors (preventing sexually transmitted infections (STIs), knowledge of contraception and effective use, etc.)
15. Tobacco, alcohol, other substance use
16. Wellness (healthy diet, nutrition, physical activity, etc.)
17. Other (please specify below)

1. Major Health Concerns for Newborns and Infants (Birth to 1 year of age)

1. N/A, I have no interest and/or involvement with this population.
2. Behavioral and mental health
3. Breastfeeding, education and support
4. Developmental screenings
5. Genetic testing and counseling
6. Growth and development
7. Healthy relationships
8. Newborn care in home
9. Oral health
10. Parenting education
11. Postpartum education
12. Quality child care
13. Safe sleep and Sudden unexpected infant deaths (SUIDS)
14. Other (please specify below)

1. Major Health Concerns for Young Children (1 - 5 years of age)

1. N/A, I have no interest and/or involvement with this population.
2. Behavioral and mental health
3. Bullying
4. Developmental screenings
5. Growth and development
6. Immunizations (up to date)
7. Medical specialty care
8. Nurturing environment and healthy families
9. Obesity
10. Oral health
11. Parenting education
12. Quality child care and early education
13. Safety and injury prevention
14. Wellness (healthy diet, nutrition, physical activity, etc.)
15. Other (please specify below)

1. Major Health Concerns for Children (6 - 11 years of age)

1. N/A, I have no interest and/or involvement with this population.
2. After school care
3. Behavioral and mental health
4. Bullying
5. Chronic conditions (asthma, diabetes, etc.)
6. Developmental screenings
7. Growth and development
8. Immunizations (up to date)
9. Medical specialty care
10. Nurturing environment and healthy families
11. Obesity
12. Oral health
13. Parenting education
14. Safety and injury prevention
15. School health services
16. Wellness (healthy diet, nutrition, physical activity, etc.)
17. Other (please specify below)

1. Major Health Concerns for Youth and Adolescents (12 - 18 years of age)

1. N/A, I have no interest and/or involvement with this population.
2. Behavioral and mental health
3. Bullying
4. Chronic conditions (diabetes, high blood pressure, asthma, etc.)
5. Developmental screenings
6. Growth and development
7. Health screening and preventive behaviors
8. Healthy relationships
9. Immunizations (up to date)
10. Obesity
11. Oral health
12. Parenting education
13. Reproductive health education
14. Safety and injury prevention
15. School health services
16. Sexual behaviors (preventing sexually transmitted infections (STIs), pregnancy prevention/knowledge of contraception and effective use, etc.)
17. Tobacco, alcohol, other substance use
18. Wellness (healthy diet, nutrition, physical activity, etc.)
19. Other (please specify below)

1. Major Health Concerns for Children with Special Health Care Needs (Birth to 11 years of age)
2. N/A,I have no interest and/or involvement with this population.
3. Access to services
4. Adequate health insurance coverage
5. Behavioral and mental health
6. Care coordination
7. Complex chronic conditions (ADD/ADHD, asthma, autism spectrum disorder, diabetes etc.)
8. Developmental screenings
9. Family education and support
10. Growth and development
11. Immunizations (up to date)
12. Obesity
13. Oral health
14. Preventive care
15. Referral services
16. Respite care
17. Safety and injury prevention
18. School health services
19. Wellness (healthy diet, nutrition, physical activity, etc.)
20. Other (please specify)

1. What specific recommendations do you have for improving the health of mothers, children and families in the state? (Examples may include but are not limited to: collect certain types of data to better understand an issue; improve availability, development, or quality of programs; fixing an existing policy that impacts health; share information with the public to provide education about a specific policy).

1. What specific groups/ populations or specific locations in the state need additional supports? Please indicate who or where and what types of supports are needed.

1. Considering any specific programs you have worked with or services you have received, what parts ARE working well? Please be specific (e.g. program name, local or state-level, etc.).

1. Considering any specific programs you have worked with or services you have received, what parts ARE NOT working well? Please be specific (e.g. program name, local or state-level, etc.).

1. Would you be willing to participate in opportunities to provide input on future MCH program initiatives? Please consider sharing your name and the best way to contact you (phone number or email address).

1. Yesb. No

Name:

Phone Number:

Email Address:

Thank you, the RI Department of Health greatly appreciates you providing your feedback!

State of Rhode Island and Providence Plantations