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ICF Individual, Family & Guardian Satisfaction Survey
Please take a few moments to give us your feedback.
3
Questions
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1
Please choose which ICF location you/individual lives in:
Park West
Johnstown
Park West
Johnstown
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2
Are you your own guardian?
Yes
No
Yes
No
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3
Individual's Name:
*
This field is required.
First Name
Last Name
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4
Family/Guardian Name:
*
This field is required.
First Name
Last Name
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5
Do staff and nurses help the individual when they are sick?
*
This field is required.
Yes
Sometimes
No
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6
Do staff and nurses help you when you are sick?
*
This field is required.
Yes
Sometimes
No
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7
Does the individual feel safe at home?
*
This field is required.
Yes
Sometimes
No
Unable to determine
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8
Do you feel safe at your home?
*
This field is required.
Yes
Sometimes
No
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9
Does the individual get to go to all of their appointments and activities?
*
This field is required.
Yes
Sometimes
No
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10
Do you get to go to all of your appointments and activities?
*
This field is required.
Yes
Sometimes
No
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11
Does the individual participate as much as possible in their person centered plan?
*
This field is required.
Yes
Sometimes
No
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12
Do you get to participate as much as you would like in your person centered plan?
*
This field is required.
Yes
Sometimes
No
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13
Is the individual happy with their home (housemates, neighbors, etc.)?
*
This field is required.
Yes
Sometimes
No
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14
Are you happy with your home (housemates, neighbors, etc.)?
*
This field is required.
Yes
Sometimes
No
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15
Do staff treat the individual with respect?
*
This field is required.
Yes
Sometimes
No
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16
Do staff treat you with respect?
*
This field is required.
Yes
Sometimes
No
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17
Do staff let the individual make choices?
*
This field is required.
Yes
Sometimes
No
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18
Do staff let you make choices?
*
This field is required.
Yes
Sometimes
No
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19
Is Open Door staff friendly when you visit the home/facility?
*
This field is required.
Yes
Sometimes
No
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20
Is Open Door staff friendly to you?
*
This field is required.
Yes
Sometimes
No
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21
Do staff take the individual to do what they want to do?
*
This field is required.
Yes
Sometimes
No
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22
Do staff take you to do what you want to do?
*
This field is required.
Yes
Sometimes
No
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23
Does the individual get to visit their family or friends as often as they want?
Yes
Sometimes
No
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24
Do you get to visit your family or friends as often as you want?
Yes
Sometimes
No
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25
Does the QIDP help/spend time with the individual?
Yes
Sometimes
No
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26
Does your QIDP help/spend time with you?
Yes
Sometimes
No
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27
Are you happy with the help that the individual receives budgeting their money?
*
This field is required.
Yes
Sometimes
No
N/A
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28
Are you happy with the help that you receive budgeting your money?
*
This field is required.
Yes
Sometimes
No
N/A
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29
We value your opinion, and the opinions of the individuals we support, and want to take steps to correct any issues that need to be addressed. Please provide details/explanation for any questions that you answered "sometimes" or "no" to so that we can ensure proper follow-up.
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30
Is there anything else that you would like us to know?
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