Family Care & Group Home Consumer Satisfaction Survey

This survey is for persons who live in a Family Care Home or in a group home.

We would like to know how well we are doing in supporting you. This survey is confidential, which means that nobody will find out your answers. Everybody’s answers will be collected and combined into one report.

You can fill out this survey on your own, or you may ask for help. You may want to ask a friend, family member, and caregiver or staff person to help you.

When you have completed your survey, please press DONE.

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* Indicate the region you reside in

Lower Mainland

Fraser Valley

Powell River

Sunshine Coast

Kelowna

Question Title

* Please indicate what program you reside in:

Family Care Home for Adults

Hybrid Home Share for Adults

Family Care Home for Children and Youth

Residential Group Home for Adults

Adult Specialized Resource (MC Rox)

Children and Youth Specialized Resource

Question Title

* How much assistance are you recieving to complete this survey:

Without assistance

With some assistance

With full assistance

Relationship of person who assisted you:

Question Title

* What aspects of your home do you like?

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* What aspects of your home do you dislike?

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* What changes would you like to see in your home?

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* SERVICES/ SUPPORTS COORDINATION

	Yes	Sometimes	No	N/A
1. My staff/caregiver helps me to achieve my goals.	1. My staff/caregiver helps me to achieve my goals. Yes	1. My staff/caregiver helps me to achieve my goals. Sometimes	1. My staff/caregiver helps me to achieve my goals. No	1. My staff/caregiver helps me to achieve my goals. N/A
2. My staff/caregiver helps me stay in touch with family and friends.	2. My staff/caregiver helps me stay in touch with family and friends. Yes	2. My staff/caregiver helps me stay in touch with family and friends. Sometimes	2. My staff/caregiver helps me stay in touch with family and friends. No	2. My staff/caregiver helps me stay in touch with family and friends. N/A
3. My staff/caregiver lets me know when I am doing a good job.	3. My staff/caregiver lets me know when I am doing a good job. Yes	3. My staff/caregiver lets me know when I am doing a good job. Sometimes	3. My staff/caregiver lets me know when I am doing a good job. No	3. My staff/caregiver lets me know when I am doing a good job. N/A
4. I receive extra support from my staff/caregivers when I need it.	4. I receive extra support from my staff/caregivers when I need it. Yes	4. I receive extra support from my staff/caregivers when I need it. Sometimes	4. I receive extra support from my staff/caregivers when I need it. No	4. I receive extra support from my staff/caregivers when I need it. N/A

Question Title

* COMMUNITY INCLUSION

	Yes	Sometimes	No	N/A
5. I am supported to access activities in the community.	5. I am supported to access activities in the community. Yes	5. I am supported to access activities in the community. Sometimes	5. I am supported to access activities in the community. No	5. I am supported to access activities in the community. N/A
6. I like the community I live in.	6. I like the community I live in. Yes	6. I like the community I live in. Sometimes	6. I like the community I live in. No	6. I like the community I live in. N/A
7. I like my home.	7. I like my home. Yes	7. I like my home. Sometimes	7. I like my home. No	7. I like my home. N/A
8. I have an opportunity to visit my family and friends.	8. I have an opportunity to visit my family and friends. Yes	8. I have an opportunity to visit my family and friends. Sometimes	8. I have an opportunity to visit my family and friends. No	8. I have an opportunity to visit my family and friends. N/A

Question Title

* RIGHTS

	Yes	Sometimes	No	N/A
9. My staff/caregiver treats me with respect.	9. My staff/caregiver treats me with respect. Yes	9. My staff/caregiver treats me with respect. Sometimes	9. My staff/caregiver treats me with respect. No	9. My staff/caregiver treats me with respect. N/A
10. I feel that I can make my own choices and decisions.	10. I feel that I can make my own choices and decisions. Yes	10. I feel that I can make my own choices and decisions. Sometimes	10. I feel that I can make my own choices and decisions. No	10. I feel that I can make my own choices and decisions. N/A
11. I feel that my personal records are kept private unless I give my permission.	11. I feel that my personal records are kept private unless I give my permission. Yes	11. I feel that my personal records are kept private unless I give my permission. Sometimes	11. I feel that my personal records are kept private unless I give my permission. No	11. I feel that my personal records are kept private unless I give my permission. N/A
12. I am treated well by staff/caregiver.	12. I am treated well by staff/caregiver. Yes	12. I am treated well by staff/caregiver. Sometimes	12. I am treated well by staff/caregiver. No	12. I am treated well by staff/caregiver. N/A
13. The staff/caregiver helps me when I ask them to.	13. The staff/caregiver helps me when I ask them to. Yes	13. The staff/caregiver helps me when I ask them to. Sometimes	13. The staff/caregiver helps me when I ask them to. No	13. The staff/caregiver helps me when I ask them to. N/A
14. The staff/caregiver listens to me when I have something to say.	14. The staff/caregiver listens to me when I have something to say. Yes	14. The staff/caregiver listens to me when I have something to say. Sometimes	14. The staff/caregiver listens to me when I have something to say. No	14. The staff/caregiver listens to me when I have something to say. N/A
15. I feel that I can provide input into decisions about my home environment.	15. I feel that I can provide input into decisions about my home environment. Yes	15. I feel that I can provide input into decisions about my home environment. Sometimes	15. I feel that I can provide input into decisions about my home environment. No	15. I feel that I can provide input into decisions about my home environment. N/A

Question Title

* Health

	Yes	Sometimes	No	N/A
16. My staff/caregiver takes me to the doctor whenever I need to go.	16. My staff/caregiver takes me to the doctor whenever I need to go. Yes	16. My staff/caregiver takes me to the doctor whenever I need to go. Sometimes	16. My staff/caregiver takes me to the doctor whenever I need to go. No	16. My staff/caregiver takes me to the doctor whenever I need to go. N/A
17. My staff/caregiver makes sure that I am healthy and takes care of me when I’m sick.	17. My staff/caregiver makes sure that I am healthy and takes care of me when I’m sick. Yes	17. My staff/caregiver makes sure that I am healthy and takes care of me when I’m sick. Sometimes	17. My staff/caregiver makes sure that I am healthy and takes care of me when I’m sick. No	17. My staff/caregiver makes sure that I am healthy and takes care of me when I’m sick. N/A

	Yes	Sometimes	No	N/A
18. I feel safe in my home.	18. I feel safe in my home. Yes	18. I feel safe in my home. Sometimes	18. I feel safe in my home. No	18. I feel safe in my home. N/A
19. I live in a stable home environment.	19. I live in a stable home environment. Yes	19. I live in a stable home environment. Sometimes	19. I live in a stable home environment. No	19. I live in a stable home environment. N/A
20. When I want to go somewhere, I have a way to get there.	20. When I want to go somewhere, I have a way to get there. Yes	20. When I want to go somewhere, I have a way to get there. Sometimes	20. When I want to go somewhere, I have a way to get there. No	20. When I want to go somewhere, I have a way to get there. N/A
21. I feel safe in the community.	21. I feel safe in the community. Yes	21. I feel safe in the community. Sometimes	21. I feel safe in the community. No	21. I feel safe in the community. N/A
22. I practice emergency safety drills.	22. I practice emergency safety drills. Yes	22. I practice emergency safety drills. Sometimes	22. I practice emergency safety drills. No	22. I practice emergency safety drills. N/A
23. I have adaptive equipment and home modifications accessible to me if I need it, such as lifts, wheelchairs, ramps etc.	23. I have adaptive equipment and home modifications accessible to me if I need it, such as lifts, wheelchairs, ramps etc. Yes	23. I have adaptive equipment and home modifications accessible to me if I need it, such as lifts, wheelchairs, ramps etc. Sometimes	23. I have adaptive equipment and home modifications accessible to me if I need it, such as lifts, wheelchairs, ramps etc. No	23. I have adaptive equipment and home modifications accessible to me if I need it, such as lifts, wheelchairs, ramps etc. N/A

Family Care & Group Home Consumer Satisfaction Survey

1. Survey

Question Title

* Indicate the region you reside in

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* Please indicate what program you reside in:

Question Title

* How much assistance are you recieving to complete this survey:

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* What aspects of your home do you like?

Question Title

* What aspects of your home do you dislike?

Question Title

* What changes would you like to see in your home?

Question Title

* SERVICES/ SUPPORTS COORDINATION

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* COMMUNITY INCLUSION

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* RIGHTS

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* Health

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* ACCESS & SECURITY

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* Overall I would rate my satisfaction with the quality of the program as: