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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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* 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.

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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?

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