Family Perspective of Provider Interactions and Services

This survey seeks to collect information from families, guardians and individuals with developmental disabilities about the quality of home and community based support and services available to adults with developmental disabilities. The purpose is to gather feedback on the concerns and/or confidence that individuals and their families have in service providers for those with developmental disabilities. You may remain anonymous if so desired.

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* 1. A little about you. I am the ...

...Family member of an individual with a disability

... Guardian of an individual with a disability AND a family member

... Guardian of an individual with a disability but NOT a family member

... Individual with a disability

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* 2. How old is the family member with a developmental disability (or the person for whom you are the guardian)? Or if answering for yourself, how old are you?

18 - 22 years

23- 30 years

31 - 40 years

41 - 50 years

51 - 60 years

60 + years

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* 3. In what county does the adult with a developmental disability live?

Stark

Summit

Other (please specify)

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* 4. What is the residential situation of the adult with a developmental disability?

Lives in family home

Lives in a home (house or apartment) in the community with no roommates

Lives in a home (house or apartment) in the community with roommates

Lives in a large congregate setting such as a Developmental Center

Other (please specify)

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* 5. What statement MOST CLOSELY describes the communication of the adult with a developmental disability?

No functional communication, either through verbalizations, gestures, or supports such as visual supports, assistive technology device, etc.

Limited communication, can communicate some basic needs through verbalizations, gestures, or supports such as visual supports, assistive technology device, etc.

Communicates basic needs and limited social communication through verbalizations, gestures, or supports such as visual supports, assistive technology device, etc.

Speech is typical but has difficulty with understanding others, especially social interactions, body language and facial expressions.

Communication patterns are mostly typical with occasional difficulty occurring, such as in new situations, new people, or when very stressed

Communication skills and abilities are typical.

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* 6. Does the adult with a developmental disability ever experience behavioral challenges?

Yes. Frequent and can include aggressive, self-abusive, or destructive behaviors

Yes. Sometimes and can include aggressive, self-abusive, or destructive behaviors

Yes. Occasionally and can include aggressive, self-abusive, or destructive behaviors

Yes. Frequent but does NOT include aggressive, self-abusive, or destructive behaviors

Yes. Sometimes but does NOT include aggressive, self-abusive, or destructive behaviors

Yes. Occasionally but does NOT include aggressive, self-abusive, or destructive behaviors

No. There are no behavior challenges.

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* 7. Is the adult with the developmental disability eligible for services and support from your County Board of Developmental Disabilities (CBDD) /Department of Developmental Disabilities (DODD)?

Yes

I do not know

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* 8. How much support does the adult with the developmental disability receive ?
Please select the answer that MOST CLOSELY reflects the total amount of support received (paid or natural), including support from family, friends and provider agency.

Continuous support or monitoring (24/7)

Daily assistance with activities such as meal preparation, laundry, medication preparation/administration, etc. but can be alone for short periods of time.

Periodic check -ins during the day or every few days and is able to be alone for long periods of time or even overnight.

Only assistance for specific situations such as transportation or unusual occurrences.

Requires no assistance. Independent.

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* 9. Has the adult with a developmental disability EVER received support or services from a paid provider to assist in the home, community activities, or employment (from someone other than volunteer, family or friends) ?

Yes

I do not know

Family Perspective of Provider Interactions and Services

Question Title

* 1. A little about you. I am the ...

Question Title

* 2. How old is the family member with a developmental disability (or the person for whom you are the guardian)? Or if answering for yourself, how old are you?

Question Title

* 3. In what county does the adult with a developmental disability live?

Question Title

* 4. What is the residential situation of the adult with a developmental disability?

Question Title

* 5. What statement MOST CLOSELY describes the communication of the adult with a developmental disability?

Question Title

* 6. Does the adult with a developmental disability ever experience behavioral challenges?

Question Title

* 7. Is the adult with the developmental disability eligible for services and support from your County Board of Developmental Disabilities (CBDD) /Department of Developmental Disabilities (DODD)?

Question Title

* 8. How much support does the adult with the developmental disability receive ? Please select the answer that MOST CLOSELY reflects the total amount of support received (paid or natural), including support from family, friends and provider agency.

Question Title

* 9. Has the adult with a developmental disability EVER received support or services from a paid provider to assist in the home, community activities, or employment (from someone other than volunteer, family or friends) ?

* 8. How much support does the adult with the developmental disability receive ?
Please select the answer that MOST CLOSELY reflects the total amount of support received (paid or natural), including support from family, friends and provider agency.