FOOTPRINTS and PINETREE PARTICIPANT SATISFACTION SURVEY

Question Title

* Place checkmark beside the location where your day program is run out of.

Footprints Day Centre

Pinetree Day Centre

Windridge

Blueridge

Kerrywood

Windsong

Private Home

This survey is for persons who attend the Footprints and PineTree Day Program.

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.

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:

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* What aspects of the Footprints program do you like?

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* What aspects of the Footprints program do you dislike?

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* What changes would you like to see in the Footprints program?

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* Personal Goals

	Yes	Sometimes	No	N/A
1. I am supported by my staff to strive towards and accomplish my goals.	1. I am supported by my staff to strive towards and accomplish my goals. Yes	1. I am supported by my staff to strive towards and accomplish my goals. Sometimes	1. I am supported by my staff to strive towards and accomplish my goals. No	1. I am supported by my staff to strive towards and accomplish my goals. N/A

Question Title

* STAFFING SUPPORT

	Yes	Sometimes	No	N/A
2. I enjoy spending time with my staff.	2. I enjoy spending time with my staff. Yes	2. I enjoy spending time with my staff. Sometimes	2. I enjoy spending time with my staff. No	2. I enjoy spending time with my staff. N/A
3. My staff lets me know what the plans are for the day.	3. My staff lets me know what the plans are for the day. Yes	3. My staff lets me know what the plans are for the day. Sometimes	3. My staff lets me know what the plans are for the day. No	3. My staff lets me know what the plans are for the day. N/A
4. My staff involves me in planning my schedule.	4. My staff involves me in planning my schedule. Yes	4. My staff involves me in planning my schedule. Sometimes	4. My staff involves me in planning my schedule. No	4. My staff involves me in planning my schedule. N/A
5. I am encouraged by my staff to try new things and go to different places.	5. I am encouraged by my staff to try new things and go to different places. Yes	5. I am encouraged by my staff to try new things and go to different places. Sometimes	5. I am encouraged by my staff to try new things and go to different places. No	5. I am encouraged by my staff to try new things and go to different places. N/A

Question Title

* COMMUNITY INCLUSION

	Yes	Sometimes	No	N/A
6. I am satisfied with the activities and programs I participate in.	6. I am satisfied with the activities and programs I participate in. Yes	6. I am satisfied with the activities and programs I participate in. Sometimes	6. I am satisfied with the activities and programs I participate in. No	6. I am satisfied with the activities and programs I participate in. N/A
7. I feel that I am part of my community.	7. I feel that I am part of my community. Yes	7. I feel that I am part of my community. Sometimes	7. I feel that I am part of my community. No	7. I feel that I am part of my community. N/A
8. I participate in recreational programs that I enjoy such as bowling, hiking, sailing, cooking, swimming, etc.	8. I participate in recreational programs that I enjoy such as bowling, hiking, sailing, cooking, swimming, etc. Yes	8. I participate in recreational programs that I enjoy such as bowling, hiking, sailing, cooking, swimming, etc. Sometimes	8. I participate in recreational programs that I enjoy such as bowling, hiking, sailing, cooking, swimming, etc. No	8. I participate in recreational programs that I enjoy such as bowling, hiking, sailing, cooking, swimming, etc. N/A
9. My staff and I go out with other people and engage in social activities.	9. My staff and I go out with other people and engage in social activities. Yes	9. My staff and I go out with other people and engage in social activities. Sometimes	9. My staff and I go out with other people and engage in social activities. No	9. My staff and I go out with other people and engage in social activities. N/A
10. I go to special events in the community such as concerts, PNE, festivals, sporting events, etc.	10. I go to special events in the community such as concerts, PNE, festivals, sporting events, etc. Yes	10. I go to special events in the community such as concerts, PNE, festivals, sporting events, etc. Sometimes	10. I go to special events in the community such as concerts, PNE, festivals, sporting events, etc. No	10. I go to special events in the community such as concerts, PNE, festivals, sporting events, etc. N/A
11. I access the community for leisure activities eg. Movie theatres, parks, beaches, community centres, etc.	11. I access the community for leisure activities eg. Movie theatres, parks, beaches, community centres, etc. Yes	11. I access the community for leisure activities eg. Movie theatres, parks, beaches, community centres, etc. Sometimes	11. I access the community for leisure activities eg. Movie theatres, parks, beaches, community centres, etc. No	11. I access the community for leisure activities eg. Movie theatres, parks, beaches, community centres, etc. N/A

Question Title

* RIGHTS

	Yes	Sometimes	No	N/A
12. My staff is respectful of my rights.	12. My staff is respectful of my rights. Yes	12. My staff is respectful of my rights. Sometimes	12. My staff is respectful of my rights. No	12. My staff is respectful of my rights. N/A
13. My staff protects me from abuse and neglect.	13. My staff protects me from abuse and neglect. Yes	13. My staff protects me from abuse and neglect. Sometimes	13. My staff protects me from abuse and neglect. No	13. My staff protects me from abuse and neglect. N/A
14. I feel that my privacy is respected.	14. I feel that my privacy is respected. Yes	14. I feel that my privacy is respected. Sometimes	14. I feel that my privacy is respected. No	14. I feel that my privacy is respected. N/A
15. I am treated well by my staff.	15. I am treated well by my staff. Yes	15. I am treated well by my staff. Sometimes	15. I am treated well by my staff. No	15. I am treated well by my staff. N/A
16. My staff helps me when I ask them to.	16. My staff helps me when I ask them to. Yes	16. My staff helps me when I ask them to. Sometimes	16. My staff helps me when I ask them to. No	16. My staff helps me when I ask them to. N/A
17. My staff listens to me when I have something to say.	17. My staff listens to me when I have something to say. Yes	17. My staff listens to me when I have something to say. Sometimes	17. My staff listens to me when I have something to say. No	17. My staff listens to me when I have something to say. N/A

Question Title

* HEALTH

	Yes	Sometimes	No	N/A
18. I trust my staff to monitor my health when I am with them.	18. I trust my staff to monitor my health when I am with them. Yes	18. I trust my staff to monitor my health when I am with them. Sometimes	18. I trust my staff to monitor my health when I am with them. No	18. I trust my staff to monitor my health when I am with them. N/A

Question Title

* SAFETY & SECURITY

	Yes	Sometimes	No	N/A
19. I feel safe when I am with my staff at home and in the community.	19. I feel safe when I am with my staff at home and in the community. Yes	19. I feel safe when I am with my staff at home and in the community. Sometimes	19. I feel safe when I am with my staff at home and in the community. No	19. I feel safe when I am with my staff at home and in the community. N/A
20. My staff knows how to assist me in the event of an emergency.	20. My staff knows how to assist me in the event of an emergency. Yes	20. My staff knows how to assist me in the event of an emergency. Sometimes	20. My staff knows how to assist me in the event of an emergency. No	20. My staff knows how to assist me in the event of an emergency. N/A

FOOTPRINTS and PINETREE PARTICIPANT SATISFACTION SURVEY

1. Survey

Question Title

* Place checkmark beside the location where your day program is run out of.

Question Title

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

Question Title

* What aspects of the Footprints program do you like?

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* What aspects of the Footprints program do you dislike?

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* What changes would you like to see in the Footprints program?

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* Personal Goals

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* STAFFING SUPPORT

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* COMMUNITY INCLUSION

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* RIGHTS

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* HEALTH

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* SAFETY & SECURITY

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