Chance 4 Change - Consumer Survey

Consumer Survey

Chance 4 Change, Inc.
Family/Consumer/Support Team Survey 2010

SURVEY INSTRUCTIONS

Please use the five ratings ranging from Always to Never to indicate your level of satisfaction, need, experience, etc.

Please circle only one answer for each question. Questions with more than one answer circled cannot be included in the survey results.

If a section does not apply to your family or consumer, skip to the next section. If a question within a section does not apply to your family or consumer, circle N/A (not applicable).

If you have any questions on this survey, or need any additional information before beginning, please contact: Jill Powell at jillp@chance4change.net or call (916) 870-9590.

Please note that there are questions on both sides of each page.

Please use the space provided on the last page of this survey to share comments.

All survey responses are confidential.

This survey should take approximately 15 minutes to complete.

A. Name of Supporting Agency and Location:

B. What is your relationship to the family or consumer receiving services?

Parent
Self
Other Relative (Example: Aunt, Uncle, Grandparents, etc.)
Other (Please Specify)

C. What is the age of the individual receiving services?

Part I. Overall Supports and Services to Families and Consumers

Are you satisfied with the informational materials you receive from the Agency? (Ex: trainings, workshops, events, policy changes, newsletters, etc.)

Always Usually Sometimes Seldom Never N/A
Do you need information about community resources, services and supports?

Yes No
1. Are you satisfied with the information about community resources, services and supports that you receive from the Agency?
  
  Always Usually Sometimes Seldom Never N/A
Does the agency keep you informed about upcoming legislation relative to developmental disabilities?

Always Usually Sometimes Seldom Never N/A
1. Does the Area Agency keep you informed about legislative outcomes relative to developmental disabilities?
  
  Always Usually Sometimes Seldom Never N/A
Are you satisfied with the level of responsiveness when you have contact with the Agency?

Always Usually Sometimes Seldom Never N/A
Did the Agency inform you of your family member’s rights as a consumer of services in the Developmental Services System?

Yes No
1. If yes, do you understand these rights?
  
  Yes No
2. If yes, do you know whom to contact at the Agency if you have a concern or complaint about these rights?
  
  Yes No
Do you need support in your efforts to direct the planning and carrying out of your services?

Yes No
1. Are you satisfied with the Agency’s support of your efforts to direct the planning and carrying out of your services?
  
  Always Usually Sometimes Seldom Never N/A
2. Are you satisfied with your level of involvement in service planning?
  
  Always Usually Sometimes Seldom Never N/A
Are the supports your family member or consumer needs available?

Always Usually Sometimes Seldom Never N/A
1. Are you satisfied with the assistance the Agency provides toward meeting your family member or consumers needs?
  
  Always Usually Sometimes Seldom Never N/A
Are your family member or consumers most important goals being met?

Always Usually Sometimes Seldom Never N/A
1. Are you satisfied with the Area Agency’s assistance in meeting your family member’s most important goals?
  
  Always Usually Sometimes Seldom Never N/A
If your family member or consumer is on the Waiting List for services, does someone from the Area Agency provide you with status updates?

Always Usually Sometimes Seldom Never N/A
Are you satisfied that the Agency address the safety needs of your family member or consumer?

Always Usually Sometimes Seldom Never N/A
Are you satisfied that the Agency address the health needs of your family member or consumer?

Always Usually Sometimes Seldom Never N/A
Are you satisfied that the Agency address your family member’s or consumers dental needs?

Always Usually Sometimes Seldom Never N/A
Are you satisfied that the Agency address your family member’s or consumers mental health/behavioral support needs?

Always Usually Sometimes Seldom Never N/A

Part II. Service Coordination

Please answer the questions 18 through 25 regarding the person at the area agency who coordinates your family members services.

Does the CSF understand the needs of your family member or consumer?

Always Usually Sometimes Seldom Never N/A
Does the CSF communicate with your family or consumer on an ongoing basis?

Always Usually Sometimes Seldom Never N/A
Does the CSF respond to your requests in a timely manner?

Always Usually Sometimes Seldom Never N/A
Does the CSF treat your family member or consumer with dignity and respect?

Always Usually Sometimes Seldom Never N/A
Does the CSF satisfactorily organize support services for you family member or consumer?

Always Usually Sometimes Seldom Never N/A
Does the CSF support your efforts in advocating for your family member or consumer?

Always Usually Sometimes Seldom Never N/A
Does the support you receive help your family member or consumer to become more connected to the community?

Always Usually Sometimes Seldom Never N/A

Part III. The Adult Years (21 years of age and up)

Please answer questions 31 through 45b regarding your adult family member.

Does your family member receive day* or residential** services coordinated through the Regional Center?

Yes No

(*Day services typically involve your family member leaving his/her home, during day-time hours, to participate in community activities, volunteering, work, continuing education, etc.)

(**Residential services typically are provided in the family home to assist the family member with personal care and activities of daily living.)

IF NO, PLEASE SKIP TO SECTION IV.

If yes, please write the name(s) of the agency(s) providing these services (This may be the Area Agency. If you are unsure of the agency name, please contact your service coordinator):
1. Day Services:
2. Residential Services:

Please indicate your level of satisfaction in each of these areas:

Is the staff adequately trained and knowledgeable to support your family member or consumer?
1. Day Services Provider: Always Usually Sometimes Seldom Never N/A
2. SLS Provider: Always Usually Sometimes Seldom Never N/A
Is the staff responsive to your family’s or consumers needs, ideas, suggestions or concerns?

Day Services Provider: Always Usually Sometimes Seldom Never N/A
SLS Provider: Always Usually Sometimes Seldom Never N/A

Does the staff involve your family or consumer in planning and decision making activities?

Day Services Provider: Always Usually Sometimes Seldom Never N/A
SLS Provider: Always Usually Sometimes Seldom Never N/A

Does the staff treat your family member or consumer with dignity and respect?

Day Services Provider: Always Usually Sometimes Seldom Never N/A
SLS Provider: Always Usually Sometimes Seldom Never N/A

Does the agency providing services communicate important information and/or changes in support in a timely manner?

Day Services Provider: Always Usually Sometimes Seldom Never N/A
SLS Provider: Always Usually Sometimes Seldom Never N/A

Does your family member or consumer have opportunities to learn/maintain skills and/or develop personal interests?

Day Services Provider: Always Usually Sometimes Seldom Never N/A
SLS Provider: Always Usually Sometimes Seldom Never N/A

Is your family member or consumer provided with meaningful opportunities to participate in the community?

Day Services Provider: Always Usually Sometimes Seldom Never N/A
SLS Provider: Always Usually Sometimes Seldom Never N/A

Are your family member’s or consumers health and safety needs being met?

Day Services Provider: Always Usually Sometimes Seldom Never N/A
SLS Provider: Always Usually Sometimes Seldom Never N/A

Are you satisfied with the services being provided?

Day Services Provider: Always Usually Sometimes Seldom Never N/A
SLS Provider: Always Usually Sometimes Seldom Never N/A

If currently employed, is your family member or consumer satisfied with his/her job?

Day Services Provider: Always Usually Sometimes Seldom Never N/A
SLS Provider: Always Usually Sometimes Seldom Never N/A

Part IV. ADAPTATIONS AND ASSISTIVE DEVICES

PLEASE ANSWER QUESTIONS 46 THROUGH 47b REGARDING ADAPTATIONS AND/OR ASSISTIVE DEVICES BY YOUR FAMILY MEMBER.

Does your home need physical adaptations to make it accessible to your family member or consumer?

Yes No
1. If yes, are you satisfied with your home’s adaptations?
  
  Yes No
2. If yes, are you satisfied with the Agency’s assistance toward making your home accessible?
  
  Yes No
Does your family member or consumer need technology to improve/enhance communication?

Yes No
1. If yes, are you satisfied that up-to-date communication aids are available to your family member or consumer?
  
  Yes No
2. If yes, are you satisfied with the Agency’s assistance toward making communication aids available?
  
  Yes No

Optional

Name:

Would you like to be contacted by someone from the Agency to discuss any questions or concerns you may have?

Yes No

If yes, please provide your name, telephone number and the best time to contact you:

Phone

Best Time

Please Share Additional Comments:

3104 O Street #419 Sacramento 95816 . Telephone (916) 870-9590 . Email info@chanceforchange.net

www.chance4change.net

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