AGING WAIVER PAS CONSUMER SURVEY
Please circle the statement that best describes your answer:
Independence and Choice
The Aging Waiver Program has allowed me to live in the place I most desire.
Strongly Agree Agree Disagree Strongly Disagree
The Aging Waiver Program has allowed me to receive services in the place(s) I most desire.
Strongly Agree Agree Disagree Strongly Disagree
I am satisfied with my degree of involvement in planning and managing my services.
Strongly Agree Agree Disagree Strongly Disagree
I have enough choice in the selection of the support services and products I choose.
Strongly Agree Agree Disagree Strongly Disagree
I get just the right amount of help that I need; not more, not less.
Strongly Agree Agree Disagree Strongly Disagree
My workers do things the way I want them done.
Strongly Agree Agree Disagree Strongly Disagree
Due to my worker’s encouragement, I am more active than I used to be.
Strongly Agree Agree Disagree Strongly Disagree
My workers provide help at times that are convenient to me.
Strongly Agree Agree Disagree Strongly Disagree
Relationships
I am satisfied with my relationship with my workers.
Strongly Agree Agree Disagree Strongly Disagree
I am able to trust my workers.
Strongly Agree Agree Disagree Strongly Disagree
My worker often goes beyond his/her regular duties to help me.
Strongly Agree Agree Disagree Strongly Disagree
I am satisfied with my ongoing experience with my Aging Waiver care manager.
Strongly Agree Agree Disagree Strongly Disagree
Knowledge and Support
I understand my roles and responsibilities in the program.
Strongly Agree Agree Disagree Strongly Disagree
The materials I received at enrollment are easy to read (font size and type).
Strongly Agree Agree Disagree Strongly Disagree
The materials I received at enrollment are easy to understand.
Strongly Agree Agree Disagree Strongly Disagree
I understand my monthly care plan and what hours my worker(s) work.
Strongly Agree Agree Disagree Strongly Disagree
I know what to do if I have a problem with my worker(s).
Strongly Agree Agree Disagree Strongly Disagree
I have the right amount of ongoing communication with my Aging Waiver care manager.
Strongly Agree Agree Disagree Strongly Disagree
Health and Safety
I believe that I am safe/safer in my home with the type of services I receive or have received.
Strongly Agree Agree Disagree Strongly Disagree
I have a back-up plan that I can use in the event my regularly scheduled worker is unavailable.
Strongly Agree Agree Disagree Strongly Disagree
I am better able to manage my personal needs because of The Aging Waiver Program.
Strongly Agree Agree Disagree Strongly Disagree
The overall quality of my life is better because of The Aging Waiver Program.
Strongly Agree Agree Disagree Strongly Disagree
Narrative
How would you describe your experience with the Aging Waiver Program?
Is there anything we haven’t covered in this survey that you feel should be addressed?
Please return this survey in the pre-paid enclosed envelope by:7/31/12
Thank you for taking the time to complete this survey!
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Participant’s Name Date