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PDS Follow up/Annual QOL Survey
If the caregiver plans to answer all questions on behalf of the participant, complete all the questions. If the participant plans to answer the questions themselves, skip section I.
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Member’s FIRST Name
*
Your answer
Member’s Last Name
*
Your answer
Member's MAID #
Your answer
Waiver Program
HCB
Member’s County of Residence
Boyd
Carter
Elliot
Greenup
Lawrence
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Support Broker Agency
FIVCO
Date of Follow up Survey
MM
/
DD
/
YYYY
Consumer Age
Your answer
Consumer sex
Male
Female
Prefer not to say
Other:
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Caregiver Age
Your answer
Caregiver Sex
Female
Male
Prefer not to say
Other:
Clear selection
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