1. 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.

* Indicate the region you reside in

* Please indicate what program you reside in:

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

* What aspects of your home do you like?

* What aspects of your home do you dislike?

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


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


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


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

* Health

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


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

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