What is your age?

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* 2. What is your age?

What county do you live?

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* 3. What county do you live?

Who is your provider?

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* 4. Who is your provider?

How long have you received services?

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* 5. How long have you received services?

What is the name of the facility where you receive your day/employment service(s)?

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* 6. What is the name of the facility where you receive your day/employment service(s)?

What do you think about the facility (physical building/location) where you receive your service(s)?

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* 7. What do you think about the facility (physical building/location) where you receive your service(s)?

What do you think of the program (structure of activities, goals, events, outings, etc.)?

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* 8. What do you think of the program (structure of activities, goals, events, outings, etc.)?

Would you change anything about the day/employment program?

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* 9. Would you change anything about the day/employment program?

Any other feedback?

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* 10. Any other feedback?

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