1-1 SIL PARTICIPANT SATISFACTION SURVEY

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.

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* Indicate the region you receive SIL 1-1 services

Lower Mainland

Fraser Valley

Sunshine Coast

Powell River

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* Please indicate if you are a

Child or Youth receiving services

Adult receiving services

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

Without assistance

With some assistance

With full assistance

Relationship of person who assisted you:

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

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

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

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

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* Program and Goals

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

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* Staff Relations

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

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* Health And Safety

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

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

excellent

above average

average

below average

poor