1. Survey

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

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.

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

* What aspects of the Footprints program do you like?

* What aspects of the Footprints program do you dislike?

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

* Personal Goals

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

* STAFFING SUPPORT

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

* COMMUNITY INCLUSION

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

* RIGHTS

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

* HEALTH

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

* SAFETY & SECURITY

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

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

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