1. Survey

This survey is for persons who receive 1-1 services through the Supported Independent Living Program.

We would like to know how well we are doing in supporting you. This survey is confidential, so nobody will know your answers. Everybody’s answers will be collected and combined into one report. Your answers will assist us to target areas for improvement in the program.

You can fill out this survey on your own, or you may ask for help. You may want to ask a friend, family member, caregiver or staff person to help you.

When you have completed your survey, please press DONE.

* Indicate the region you receive SIL 1-1 services

* Please indicate if you are a

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

* What aspects of the 1-1 program do you like?

* What aspects of the 1-1 program do you dislike?

* What changes would you like to see make in the 1-1 program?

* What other support can we offer you? Please explain.

* Program and Goals

  Yes Sometimes No N/A
1. Are you satisfied with the programs you do with your 1-1 worker?
2. Are you supported by your staff to strive towards and accomplish your goals?
3. Have you learned any new skills since being in the program?
4. If yes, have you been able to apply those new skills in other areas of your life?
5. Has your independence increased since having a 1-1 worker?
6. Has your quality of life improved since having a 1-1 worker?

* Staff Relations

  Yes Sometimes No N/A
7. Is your worker reliable?
8. Is your worker punctual?
9. I enjoy spending time with my worker?
10. My worker lets me know what the plans are for the day.
11. My worker involves me in planning my schedule.
12 Does your worker treat you with respect?
13. Are you satisfied with the level of support you receive from your worker?

* Health And Safety

  Yes Sometimes No N/A
11. Do you trust your worker to monitor your health when you are with them?
12. Do you feel safe when you are with your worker?

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