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