Day Habilitation Survey

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* 1. Please state who you are (choose one that best applies):

A person with a disability receiving day habilitation services;

A family member of a person with a disability receiving day habilitation services

A professional guardian of a person receiving day habilitation services

An advocate or attorney for a person receiving day habilitation services

Any other member of the public

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* 2. Please state where you live (choose one that best applies):

Greater Boston;

Metro West;

North Shore or north of Boston;

South Shore or south of Boston;

Cape Cod or the Islands;

Central Massachusetts (Worcester County)

Western Massachusetts (Franklin, Hampshire, or Hampden Counties);

Berkshires

I live out of state;

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* 3. If you have a disability and attend day habilitation, have a family member with a disability who attends day habilitation or serve as guardian for a person with a disability who attends day habilitation, please describe the disability(ies) as best as possible. Please choose ALL that apply:

A person with an intellectual disability

A person with autism

A person with another type of developmental disability

A person who is non-verbal

A person who uses a wheelchair or another assistive mobility device or requires assistance ambulating

A person who is Deaf or Hard of Hearing

A person who is blind or has a visual impairment

A person with another type of physical disability

A person with a traumatic brain injury

A person who has mental health issues

A person who has behavioral issues

A person with another type of disability not mentioned above

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* 4. What provider agency runs the day habilitation program you attend?

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* 5. Do you receive day habilitation supplemental supports (also referred to as 1:1 or wrap funding)? Choose one that best applies:

Yes, for the whole day

Yes, for part of the day (less than 30 hours per week)

I do not know

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* 6. What other day or employment programs or supports do you participate in? Please choose ALL that apply:

Community based day supports (CBDS)

Group supported employment

Individual employment (job in the community with individual supports)

Time during the day with family or friends

None, I am in the day habilitation full time

Other (please specify)

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* 7. At your day habilitation program, during an average month, how many times do you usually have opportunities to go into the community? Choose one that best applies:

Never

One day per month

Two days per month

Four days per month (about one day per week)

Eight to twelve days per month (about two to three days per week)

Twenty days per month (about every weekday)

Other (please specify)

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* 8. When you leave your day habilitation to go into the community, please describe who is with you. Please choose one that best applies:

Only staff

One to two day habilitation participants, plus staff

Three to five day habilitation participants, plus staff

Five to seven day habilitation participants, plus staff

Other (please specify)

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* 9. If you could change or improve your day habilitation, what would you change? Please choose ALL responses that apply.

I would want to do more community activities or spend more time away from the day habilitation building

I would want to work or, if I am already working, I want to work more

I would want to attend Community Based Day Supports (CBDS) instead of day habilitation

I would have there be more staff or have better trained staff

I would change the day habilitation location to one closer to a city/town center

I would not change anything

Other (please specify)

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* 10. When you leave your day habilitation to do activities in the community, what statement best describe this experience? Choose one that best applies:

I am actively engaged and participating

I actively watch and observe

I am not engaged or participating because I am not interested in the activity

I am not engaged or participating because I do not have the staff support I need

Other (please specify)

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* 11. Please choose the statement below that best describes the understanding that day habilitation staff have about your disabilities and abilities and about the time you spend in the community. Choose the one that best applies:

Staff tend to be too guarded or protective in limiting me from being in the community

Staff are appropriately concerned, but could allow me to be in the community more with better staffing ratios or better trained staff

I agree with the perspective of my staff about how often I can and should be in the community

Staff should be more guarded or protective about how much time I can be in the community safely

Other (please specify)

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* 12. In an ideal situation, what general areas would you want addressed in the goals and objectives in your Day Habilitation Service Plan? Please choose ALL that apply.

Personal hygiene

Toileting

Activities of daily living

Social skills

Increasing skills or use of your communication device/system

Behavior

Safety awareness

Cooking skills

Money management

Academic

Physical exercise

Physical therapy related to ambulation or standing

Physical therapy related to range of motion

Occupational therapy related to fine motor skills

Occupation therapy related to sensory issues

Other (please specify)

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* 13. What do you think are the main barriers to you spending time in the community?

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* 14. Please think about any time you spend during the week outside where day habilitation staff help you be in the community. This includes time spent outdoors, at restaurants, shopping, social activities, volunteering, or recreational activities. Please describe how happy or unhappy you are with those opportunities. Please choose one that best applies.

Very unsatisfied

Mostly unsatisfied

Neutral

Mostly satisfied

Very satisfied

Not applicable, because my day habilitation staff do not bring me into the community, or do this only rarely.

Other (please specify)

Day Habilitation Survey

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* 1. Please state who you are (choose one that best applies):

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* 2. Please state where you live (choose one that best applies):

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* 3. If you have a disability and attend day habilitation, have a family member with a disability who attends day habilitation or serve as guardian for a person with a disability who attends day habilitation, please describe the disability(ies) as best as possible. Please choose ALL that apply:

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* 4. What provider agency runs the day habilitation program you attend?

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* 5. Do you receive day habilitation supplemental supports (also referred to as 1:1 or wrap funding)? Choose one that best applies:

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* 6. What other day or employment programs or supports do you participate in? Please choose ALL that apply:

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* 7. At your day habilitation program, during an average month, how many times do you usually have opportunities to go into the community? Choose one that best applies:

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* 8. When you leave your day habilitation to go into the community, please describe who is with you. Please choose one that best applies:

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* 9. If you could change or improve your day habilitation, what would you change? Please choose ALL responses that apply.

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* 10. When you leave your day habilitation to do activities in the community, what statement best describe this experience? Choose one that best applies:

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* 11. Please choose the statement below that best describes the understanding that day habilitation staff have about your disabilities and abilities and about the time you spend in the community. Choose the one that best applies:

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* 12. In an ideal situation, what general areas would you want addressed in the goals and objectives in your Day Habilitation Service Plan? Please choose ALL that apply.

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* 13. What do you think are the main barriers to you spending time in the community?

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* 15. What do you think needs to change to increase or improve the time spent in the community for people in day habilitation?