Survey Questions Does your staff at the Day Program give you information or tell you how you can request changes to the services they provide? For example, do you know how to ask your staff to update information in your plan of care? ☐Yes ☐No Does your day program staff allow you to leave during the day if you need to (i.e., can a family member/staff check you out)? ☐Yes ☐No ☐N/A applicable (the individual participates in employment services only; does not participate in Day Services) –Not Does your day program staff discuss with you the type of activities that you might like to do and do they help you plan for these types of activities? ☐Yes ☐No ☐N/A applicable (the individual participates in employment services only; does not participate in Day Services) –Not If you want to can you have a job? For example, do you have the help you need to look for a job if you want to? ☐Yes ☐No Does your staff regularly and periodically talk to you about other activities that you might be interested in? For example, do they ask you if you would like to try any new activities (non-work activities) or if you would like to explore work options? ☐Yes ☐No ☐N/A applicable (the individual participates in employment services only; does not participate in Day Services) –Not Do the people that help you treat you with respect and speak to you in a kind and respectful manner? ☐Yes ☐No Can you be alone if you want/need to be while participating in day activity? ☐Yes ☐No ☐N/A applicable (the individual participates in employment services only; does not participate in Day Services) –Not
Survey Questions Does your staff at the Day Program give you information or tell you how you can request changes to the services they provide? For example, do you know how to ask your staff to update information in your plan of care? ☐Yes ☐No Does your day program staff allow you to leave during the day if you need to (i.e., can a family member/staff check you out)? ☐Yes ☐No ☐N/A –Not applicable (the individual participates in employment services only; does not participate in Day Services) Does your day program staff discuss with you the type of activities that you might like to do and do they help you plan for these types of activities? ☐Yes ☐No ☐N/A –Not applicable (the individual participates in employment services only; does not participate in Day Services) If you want to can you have a job? For example, do you have the help you need to look for a job if you want to? ☐Yes ☐No Does your staff regularly and periodically talk to you about other activities that you might be interested in? For example, do they ask you if you would like to try any new activities (non-work activities) or if you would like to explore work options? ☐Yes ☐No ☐N/A –Not applicable (the individual participates in employment services only; does not participate in Day Services) Do the people that help you treat you with respect and speak to you in a kind and respectful manner? ☐Yes ☐No Can you be alone if you want/need to be while participating in day activity? ☐Yes ☐No ☐N/A –Not applicable (the individual participates in employment services only; does not participate in Day Services)
STP091316CG.docx