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HCBS Survey
PLEASE RESPOND BASED ON YOUR EXPERIENCE BEFORE MARCH 2020 (PRE-COVID). If you are not a service participant answer based on your observations of Futures Explored's programs and services.
If you are unable to answer question (or it is not relevant to you), please select N/A.
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Name:
*
Your answer
Relationship to Futures Explored
*
Participant in Program/Service Recipient
Family Member of a Participant
Board Member
Care Provider
Employee of Futures Explored
Other:
Required
If you are an employee, care provider, family member, or board member, please answer to the best of your ability based on your observations or knowledge of Futures Explored's programs and services.
Program (that you attend or are connected with).
*
Your answer
Where do you live? (County or City only)
*
Your answer
Do you have the opportunity to participate in community outings and activities (i.e. outings, volunteerism, working)?
Yes, as much as I want.
Yes, but I want to do this more.
No, I don't have this opportunity.
No, and I don't want to do this.
Other:
Clear selection
If you answered "yes" above, please describe the community outings or activities you have participated in before March 2020 :
Your answer
If you answered no, what best describes why you aren't able to participate in community activities during the program day.
My program doesn't have the things I want to do.
My program doesn't allow me to go into the community.
My family doesn't allow me to go into the community.
I don't want to.
Clear selection
Do you have the opportunity to interact with non-program participants and non-support staff?
Yes, as much as I want
Yes, but I would like to do this more.
No, I don't have this opportunity.
No, and I don't want to do this.
Clear selection
Are you given opportunities to search for jobs or work in jobs?
Yes, as much as I want.
Yes, but I would like more opportunities for this.
No, I don't have this opportunity.
No, and I don't want to work.
Clear selection
Are you given opportunities to search for a new job if you wanted?
Yes, all the time.
Sometimes
Never
Clear selection
Add comments (Optional)
Your answer
Do you have access to transportation that is easy for you to use and that you can use when you want to? Transportation options can include: Public transportation, Uber/Lyft, rides from family and friends, driving your own car, riding your bike, etc.
Yes, as much as I want.
Yes, but only sometimes.
No, I don't have transportation options.
No, and I don't want transportation options.
Clear selection
Add comments (Optional)
Your answer
During program time, are you able to access your personal items and money as much and you want to?
Yes, I have access to my things and money all the time.
Yes, but I only have access to my things and money certain times during the day.
No, I don't have access to my personal things and money at all during the day.
Clear selection
Add comments (Optional)
Your answer
Does your IPP from the Regional Center reflect your choices for what programs and services you want to receive?
Yes
No
I don't know or N/A
Clear selection
Add comments (Optional)
Your answer
Does your support staff explain information such as your rights and responsibilities in a way you can understand?
Yes
No
Clear selection
Add comments (Optional)
Your answer
Do you know what to do if you felt mistreated at program or by your support staff?
Yes
No
Clear selection
Is your personal information kept private and confidential at program and/or by your support staff? For instance, your personal business isn't discussed where other people can hear OR documents with your personal information are not left out for others to see.
All the time
Sometimes
Never
Other:
Clear selection
Do you have privacy while using the bathroom and/or when receiving personal care support?
All the time
Sometimes
Never
Clear selection
Add comments (optional)
Your answer
Does support staff communicate with you in a way that you are able to easily understand? (Ex: communication device, Braille, large font, sign language, your native language)
All the time
Sometimes
Never
Clear selection
Add comments (optional)
Your answer
Are you allowed to express your personal style (clothing, hair style, make up, jewelry, etc.) at program or work?
Yes, all the time.
Yes, Sometimes
No, because my personal style is not appropriate to wear to work or program.
I feel my personal style is appropriate for work or program, but I am still not allowed to wear what I want.
Other:
Clear selection
Add comments (optional)
Your answer
Do you feel that the people who support you understand your needs and interests?
All the time
Sometimes
Never
Clear selection
Add comments (optional)
Your answer
Is there someplace at program or work where you can safely store your belongings?
All the time
Sometimes
Never
Clear selection
Add comments (optional)
Your answer
Are you able to talk on the phone, text, and read mail/email in private while at program or while working with your support staff?
All the time
Sometimes
Never
Clear selection
Add comments (optional)
Your answer
Are you able to spend time alone or away from the group while at program or work?
Yes, anytime I want
Yes, sometimes
No, never
Clear selection
Add comments (optional)
Your answer
Do you feel supported by Futures Explored to make your own decisions about your life?
All the time
Sometimes
Never
Clear selection
Add comments (optional)
Your answer
Are you able to choose who supports you?
All the time
Sometimes
Never
Clear selection
Add comments (optional)
Your answer
Do you know about Futures Explored's Grievance Policy?
Yes
No
Clear selection
Add comments (optional)
Your answer
Do you know how to file a Grievance?
Yes
No
Clear selection
Add comments (optional)
Your answer
Are you able to change your program schedule or your support service schedule?
All the time
Sometimes
Never
Clear selection
Add comments (optional)
Your answer
Are you able to voice concerns about program or supports received?
All the time
Sometimes
Never
Clear selection
Add comments (optional)
Your answer
If you are of retirement age, are you supported to retire?
Yes
No
This does not apply to me/ NA
Clear selection
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Your answer
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