Skip to content
Day Habilitation Feedback
*
1.
Interviewer Name
(Required.)
*
2.
Interviewee Information
(Required.)
Name
City/Town
Email Address
Phone Number
*
3.
Interviewee County
(Required.)
*
4.
Current living arrangement of individual supported:
(Required.)
IRA
At Home with Family
Independently
Family Care
Other (please specify)
*
5.
Have you had contact with Day Habilitation staff during this crisis?
(Required.)
Yes
No
Other (please specify)
*
6.
How likely are you (or your loved one) to return to a site-based Day Habilitation setting?
(Required.)
Very Unlikely
1 star
Somewhat Unlikely
2 stars
Unsure
3 stars
Somewhat Likely
4 stars
Very Likely
5 stars
*
7.
What are your greatest concerns about the return to congregate site-based Day Habilitation services?
(Required.)
Social Distancing
Infection Control (limiting the spread of germs)
Transitional Difficulties
None
Other (please specify)
*
8.
What changes would you like to see in place to feel comfortable sending your loved one back to Day Habilitation?
(Required.)
Smaller Group Size
Changes to Transportation
Use of Masks by Individuals
Use of Masks by Staff
Testing for COVID-19
More Time Out of the Building
Other (please specify)
*
9.
Would you or your loved one be interested in riding the bus to and from program? Would you prefer other transportation options?
(Required.)
Large Bus
Small Bus
Vans
I Prefer to Drive my Loved One
Other (please specify)
*
10.
Do you have an interest in additional programming or supports during the day for your loved one?
(Required.)
Community Habilitation
Respite
Community Prevocational Services
I Do Not Want to Add Any Other Day Program Options
Other (please specify)
*
11.
What has worked for you, or has been a positive aspect of keeping your loved one home over the last several weeks?
(Required.)
*
12.
What have been the biggest challenges for you over the last several weeks?
(Required.)
*
13.
Would you have an interest in participating in additional conversations/planning about the future of Day Habilitation programs?
(Required.)
Yes, I have some specific ideas that could make things better and am willing to share
No, I do not have an interest in participating in additional planning
14.
Any final comments?
