Provider Support
Survey

Last Updated:
February 24, 2008

Satisfaction Survey

  My name is:    My age is:

  Who is helping you fill out this form? 

  My Support Coordinator is: 

  County I live in:    (don't let your answer slip when you move your mouse)

  The name and service of the provider I would like to tell you about is:
   

  About how long has this provider been providing this service to you?     

  I receive waiver services for my disability from (HCBS, FSL, GR, CDC+, don't know, Other)     

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Check YES or NO for questions you wish to answer. 
If a question is not about you, leave it blank.
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 This provider:

  1. makes me feel good, safe, and happy when I am with them.
    YES           NO
     

  2. makes me feel I am learning things and enjoying our time together.
    YES           NO
     

  3. is nice and listens to me.
    YES           NO
     

  4. asks me about my feelings and ideas.
    YES           NO
     

  5. gives me extra time to talk or do things if I need it.
    YES           NO
     

  6. lets me be part of the group when others are talking about me.
    YES           NO
     

  7. makes all my decisions for me.
    YES           NO        
     

  8. asks me if I need help before giving me help.
    YES           NO
     

  9. knocks on my door before entering.
    YES           NO
     

  10. shows up at the time and day they told me they would.
    YES           NO
     

  11. calls me early enough if they cannot come so I have time to make other plans.
    YES           NO
     

  12. helps me to try different things together.
    YES           NO
     

  13. helps me work on things that are in my support plan goals.
    YES           NO
     

  14. asks my permission  to use or touch my personal things.  
    YES           NO
     

  15. respects my personal things when they use them.
    YES           NO
     

  16. supports my privacy.
    YES           NO        
     

  17. supports what I want to do and helps me make my own decisions.
    YES           NO
     

  18. allows me to shop where I want.
    YES           NO       
     

  19. spends too much time talking to other people on their cell phone.
    YES           NO       
     

  20. helps me to feel good about myself and their services.
    YES           NO

  If you can count all your “Yes" answers, put them here:

  Comments or questions - Tell us what you would like to change: 
 

 

 
Thank you for helping us with our survey about providers and how individuals with developmental disabilities feel about them.  Also, thank you to the DELMARVA for the basis of this questionnaire.

 

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