Basic Demographic and Other Data

 
50% of survey complete.
The purpose of this survey is to gather information on provider settings where waiver services are delivered. The survey will help the Wyoming Department of Health determine compliance with the new federal and state standards for HCB Settings.

Each survey must pertain to ONE (1) provider setting where a participant you know well receives services.
Your answers will only be used to create this transition plan, and will remain confidential. Thank you for taking the time to take this survey.

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* 1. What is the name of the primary setting you will answer questions about today (like the Pearl home, XYZ Day hab, etc.):

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* 2. What is the setting type?

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* 3. Which best describes you?

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* 4. Who is the provider of services to the participant in this setting?

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* 5. What is the full address of this setting?

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