separate face-to-face survey as long as it is conducted before December 31, 2016. The survey must include the individual and also may include a family member or representative, as appropriate. Service provider staff may participate as requested by the individual and his/her family member/representative. As the Support Coordinator conducting the survey, Certain questions include an option to explain when is actually an do not influence the responses. individual’s “No” appropriate response and is not indicative of non-compliance. OCDD will analyze the responses and be responsible for identifying follow up actions. Your responsibility is to complete the surveys and submit your individuals’ responses to OCDD before December 31, 2016. Your responses should be submitted to Christy Johnson at OCDD. The information can be emailed to or faxed to 225-342-8823. Filling out the survey: Each identified individual receiving Medicaid-reimbursed HCBS for residential or non-residential (day or employment) services must receive an individual survey measuring their awareness of and access to the rights and privacy requirements outlined in the HCBS requirements. Each residents’ section on the following pages will walk you through characteristics that are expected to be present in all home and community-based settings that individuals in those settings might experience. These questions are based on guidance from the federal government, the Centers for Medicare and Medicaid. If the person is NOT receiving the types of services indicated in the questions below, then choose at the start of the section and do “N/A” not fill out any questions in that section. Only fill out questions related to the services received by the individual you are assessing. Section A Individual, Support Coordinator, Service Provider Information – Individual ID # (this is a number assigned by OCDD to each person for the purposes of this survey): Waiver Type (Select appropriate waiver type) ☐Children’s Choice Waiver ☐Residential Options Waiver ☐Supports Waiver ☐New Opportunities Waiver Region: Support Coordination Agency Name: Support Name: Coordinator’s Number of Months Support Coordinator Assigned to Individual:
separate face-to-face survey as long as it is conducted before December 31, 2016. The survey must include the individual and also may include a family member or representative, as appropriate. Service provider staff may participate as requested by the individual and his/her family member/representative. As the Support Coordinator conducting the survey, do not influence the individual’s responses. Certain questions include an option to explain when “No” is actually an appropriate response and is not indicative of non-compliance. OCDD will analyze the individuals’ responses and be responsible for identifying follow up actions. Your responsibility is to complete the surveys and submit your responses to OCDD before December 31, 2016. Your responses should be submitted to Christy Johnson at OCDD. The information can be emailed to or faxed to 225-342-8823. Filling out the survey: Each identified individual receiving Medicaid-reimbursed HCBS for residential or non-residential (day or employment) services must receive an individual survey measuring their awareness of and access to the residents’ rights and privacy requirements outlined in the HCBS requirements. Each section on the following pages will walk you through characteristics that are expected to be present in all home and community-based settings that individuals in those settings might experience. These questions are based on guidance from the federal government, the Centers for Medicare and Medicaid. If the person is NOT receiving the types of services indicated in the questions below, then choose “N/A” at the start of the section and do not fill out any questions in that section. Only fill out questions related to the services received by the individual you are assessing. Section A – Individual, Support Coordinator, Service Provider Information Individual ID # (this is a number assigned by OCDD to each person for the purposes of this survey): Waiver Type (Select appropriate waiver type) ☐Children’s Choice Waiver ☐Residential Options Waiver ☐Supports Waiver ☐New Opportunities Waiver Region: Support Coordination Agency Name: Support Coordinator’s Name: Number of Months Support Coordinator Assigned to Individual: