No (Skip to question on legal guardian) What is your POA’s relationship to you? Not Related Spouse Parent Son Daughter Brother Sister relative How satisfied are you with your POA? Very Unsatisfied Neutral Satisfied Very Unsatisfied Satisfied ❏ ❏ ❏ ❏ ❏ Do you have a legal guardian? Yes No (Skip to question on typical day) What is your guardian’s relationship to you? Not Related Parent Son Daughter Brother Sister Other relative How satisfied are you with your legal guardian? Very Unsatisfied Neutral Satisfied Very Unsatisfied Satisfied ❏ ❏ ❏ ❏ ❏ Describe a typical day. What activities do your workers and staff help you with? What services are on your Individual Service Plan (ISP)? (Check all that apply): On Service Plan (SC Participant Answer: Pre-Populate) Adult Daily Living Services Assistive Technology
No (Skip to question on legal guardian) What is your POA’s relationship to you? Not Related Spouse Parent Son Daughter Brother Sister relative How satisfied are you with your POA? Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied ❏ ❏ ❏ ❏ ❏ Do you have a legal guardian? Yes No (Skip to question on typical day) What is your guardian’s relationship to you? Not Related Parent Son Daughter Brother Sister Other relative How satisfied are you with your legal guardian? Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied ❏ ❏ ❏ ❏ ❏ Describe a typical day. What activities do your workers and staff help you with? What services are on your Individual Service Plan (ISP)? (Check all that apply): On Service Plan (SC Pre-Populate) Participant Answer: Adult Daily Living Services Assistive Technology
Participant-Review-Tool-August-15-2016.docx