Did you have a choice of a private bedroom? Yes No If no, please explain how your bedroom was determined: Section 4 - Provider Owned and Operated Residential Settings (Continued) Do you have a bedroom roommate? Yes No (Skip to question on freedom to lock/unlock bedroom door) Were you able to select who you wanted as a bedroom roommate? Yes No N/A Please explain how this was done: Do you have the freedom to lock and/or unlock your bedroom door at any time? Yes No Do others have keys to your home? Yes No If yes, what is relationship to you? Relative Non-relative N/A Do you have access to food at any time? Yes No If no, please describe when food is available:
Did you have a choice of a private bedroom? Yes No If no, please explain how your bedroom was determined: Section 4 - Provider Owned and Operated Residential Settings (Continued) Do you have a bedroom roommate? Yes No (Skip to question on freedom to lock/unlock bedroom door) Were you able to select who you wanted as a bedroom roommate? Yes No N/A Please explain how this was done: Do you have the freedom to lock and/or unlock your bedroom door at any time? Yes No Do others have keys to your home? Yes No If yes, what is relationship to you? Relative Non-relative N/A Do you have access to food at any time? Yes No If no, please describe when food is available:
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