Thank you for taking the time to complete this questionnaire developed to assist us in improving the services here at the Respite Program at Central West Specialized Developmental Services (CWSDS). Your Feedback is very important as it helps us to shape our service to better meet the needs of the individuals we support and their families.

The survey should take 5 to 10 minutes to complete & your responses are completely anonymous.

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* 1. CWSDS provides support and service to my family member in a thoughtful, kind, respectful and caring manner.

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* 2. The are opportunities for my family member and myself to be involved in the personal support planning and goal setting.

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* 3. I am kept apprised of changes in my family member's health and well-being.

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* 4. I am satisfied with my family member's participation in programs and activities within his/her home and their community.

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* 5. The home my family member lives in is inviting, comfortable and safe.

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* 6. I am satisfied with my family member's participation in Day Services or day activities.

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* 7. My family member has the opportunity to volunteer in their community.

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* 8. My family member participates in community activities as much as they want to.

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* 9. My family member has relationships in the community with people other than paid staff.

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* 10. Overall, how satisfied are you with the supports and services provided at CWSDS?

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* 11. Do you have any additional comments?

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* 12. If you would like to be contacted or speak to a member of the Quality Improvement Committee or any staff at CWSDS please provide your contact information.

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* 13. Yes, I would like (name of specific staff you would like to speak with) to contact me.

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* 14. Name (Optional unless you wish to be contacted)

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* 15. Telephone Number (Optional unless you wish to be contacted)

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* 16. E-Mail Address (Optional unless you wish to be contacted)

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