Independent Monitoring for Quality (IM4Q)
Habilitation Survey
Developed by:
Pennsylvania Office of Mental Retardation
In conjunction with the
Institute on Disabilities
February 2006
SS# ______/__ __ /______BSU# ______-______
Non- Residential Provider Agency Name :
______
County Code: __ __
Person’s address: ______
Date of Interview: __ __/__ __/______Age on Date of Interview: ______
MM DD YYYY
A. Questions with Provider Agency about services and support for the individual being surveyed
This section can be completed by the agency in advance of the interview team’s visit. When this occurs, the team should verify the answers with the agency representative with or without the person being surveyed. If this section is given to the agency at the time of the interview, the team should complete as much as possible and leave this section with the agency to send to the local IM4Q program in 10 working days.
1. For how many years has this person been enrolled with the current provider agency?
8. Not applicable 5. 11 to 15 years
1. Less than one year 6. 16 to 20 years
_____ 2. 1 to 3 years 7. 21 years or more
3. 4 to 6 years 9. Don't know, no response, unclear response
4. 7 to 10 years
2. Current type of work or day activity where individual spends most of his/her time:
1. Competitive employment 5. Facility-Based Non-Work Activities
2. Individual Supported employment 6. Community-Based Non-Work Activities
_____ 3. Group Supported Employment 9. Don't know, no response, unclear response
4. Facility-Based Work Programs
3. Secondary type of work or day activity. Indicate what other, if any, type of work or day activity the individual participates. This other work or day activity would be in addition to the one indicated in response to question #2. This secondary type of activity would constitute between 15% and 49% of the individual's time in the program. If the individual spends time in more than two secondary areas, indicate the type of program which is currently the most prevalent.
8. Not applicable. Individual attends only main program or work.
1. Competitive employment
2. Individual Supported employment
3. Group Supported Employment
_____ 4. Facility-Based Work Programs
5. Facility-Based Non-Work Activities
6. Community-Based Non-Work Activities
9. Don't know, no response, unclear response
4. Is the individual generally compensated for his/her work at or below the minimum wage? ($5.15/hr.)
8. Not applicable. Individual does not receive compensation for activities at the
program.
_____ 1. Individual is generally compensated at minimum wage or greater
2. Individual is generally compensated below minimum wage
9. Don't know, no response, unclear response
5. For how many years has this person been coming to this type of work or day program, including years that the program was located at a different location?
8. Not applicable 5. 11 to 15 years
1. Less than one year 6. 16 to 20 years
_____ 2. 1 to 3 years 7. 21 years or more
3. 4 to 6 years 9. Don't know, no response, unclear response
4. 7 to 10 years
6. Current type of work or day activities in which the individual spends the majority of his/her time.
0. Not applicable
1. Agriculture and natural resources (farming)
2. Arts Architecture, Recreation, and Communication Services
3. Business, Government, Legal, Finance and Insurance
4. Construction
5. Children's Education and Training
6. Health and Human Services
7. Hospitality, tourism, and sales (hotel/motel work, restaurant work, retail)
_____ 8. Manufacturing
9. Public Safety
10. Science, Research, Engineering and IT
11. Technical and Repair Services
12. Transportation and Distribution
13. Non-paid work related activities
14. Non-paid and non-work related activities
15. Community experience activities
16. Don't know, no response, unclear response
7. How is the individual referred to in the facility or work setting that the individual attends?
0. Not applicable 4. Client-worker
8. Employee 3. Trainee
_____ 7. Client 2. Associate
6. Consumer 1. Other
5. Worker 9. Don't know, no response, unclear response
If other, please specify: ______
8. In the last 60 calendar days, how many days was the individual present for work or day activity? Select one answer.
0. Not applicable 7. 31 to 35 days
1. 5 days or less 8. 36 to 40 days
2. 6 to 10 days 9. 40 to 45 days
_____ 3. 11 to 15 days 10. 46 to 50 days
4. 16 to 20 days 11. 51 to 55 days
5. 21 to 25 days 12. 56 to 60 days
6. 26 to 30 days 13. Don't know, no response, unclear response
9. What is the average current monthly earned gross pay of the individual for working in a facility or in an employment program? Do not include benefits such as SSI, Social Security or the value of services. Only the amount of pay reflected in the individual's paycheck should be counted.
0. Not applicable, person has no income from work
1. Less than $10 a month 13. $501-550
2. $11-30 14. $551-600
3. $30 -65 15. $601-650
4. $66-100 16. $651-700
5. $101-150 17. $701-750
_____ 6. $151-200 18. $751-800
7. $201-250 19. $801-900
8. $251-300 20. $901-1000
9. $301-350 21. $1001-1300
10. $351-400 22. $1301 - $1500
11. $401-450 23. $1501 or more
12. $451-50 24. Don't know, no response, unclear response
10. How many hours in the most current full month did the individual work to receive the amount of pay provided in the prior answer? Only hours of actual work should be counted, not time in the program or time for transportation of the individual to the program site.
0. Not applicable, person has no income from work
2. 10 hours or less/month 11. 91 to 100 hours
3. 11 to 20 hours 12. 101 to 110 hours
4. 21 to 30 hours 13. 111 to 120 hours
_____ 5. 31 to 40 hours 14. 121 to 130 hours
6. 41 to 50 hours 15. 131 to 140 hours
7. 51 to 60 hours 16. 141 to 150 hours
8. 61 to 70 hours 17. 151 hours or more
9. 71 to 80 hours 18. Don't know, no response, unclear response
10. 81 to 90 hours
11. How many hours per day does the business/program that the individual attends normally operate? If the individual is in competitive employment or supported employment, count the employer's business hours, if known. (Check one of the options below. Round to the nearest whole number. )
0. Not applicable 6. 11 to 12 hours
1. 2 hours of less per day 7. 13 to 14 hours
_____ 2. 3 to 4 hours 8. 15 to 16 hours
3. 5 to 6 hours 9. 17 hours or more
4. 7 to 8 hours 10. Don’t know, no response, unclear response
5. 9 to 10 hours
12. Does the individual receive any one of the following employee or work benefits through your agency or through his/her employer? Paid vacation, Paid holidays, Paid sick leave, Paid personal days
8. Not applicable, person is not in a work program
1. Yes, the individual receives all four benefits for the individual
_____ 2. Yes, the individual receives 2 to 3 of the benefits for the individual
3. Yes, the individual receives one of the benefits
4. No
9. Don't know, no response, unclear response
13. Does the individual have access to any one of the following employee or work benefits through your agency or through his/her employer? FICA, Bonus program based on productivity, Employer-provided health insurance option (do not include MAWD- Medical Assistance for Workers with Disabilities), Retirement or pension option including 401K, Life insurance option
8. Not applicable, person is not in a work program
1. Yes we provide all five benefits for the individual
_____ 2. Yes we provide 2-4 of the benefits for the individual
3. Yes, we provide 1 of the benefits for the individual
4. No
9. Don't know, no response, unclear response
14. If the individual is hurt on the job or in the program, is he or she eligible for workers compensation?
8. Not applicable
1. Yes
_____ 0. No
9. Don't know, no response, unclear response
If no, is an individual hurt on the job covered by the agency's liability insurance program?
8. Not applicable
1. Yes
_____ 0. No
9. Don't know, no response, unclear response
15. How many people with mental retardation and other disabilities who are supported by your agency are known to be working or participating at the work or program site that the individual attends? (This includes both facility-based, supported employment and competitive employment settings. If the building where the work is performed houses a number of your agency's programs; count all people with disabilities who your agency supports in the building)
0. Not applicable
1. 0. The individual is the only person with a disability who the agency supports working at this site
2. 3 or fewer people with disabilities who the agency supports work at this site
3. 4 to 10 people with disabilities who the agency supports work at this site
4. 11-20
5. 21-30
6. 31-40
7. 41-50
8. 51-60
_____ 9. 61-70
10. 71-80
11. 81-90
12. 91-100
13. 101-150
14. 151-200
15. 201-250
16. 251-300
17. 301 and more
18. Don't know, no response, unclear response
16. Does your agency provide residential (6400, 6500, ICF/MR) or family resource (FRS and FDFSS) services for this individual or his/her family?
1. Yes, both residential and family resource services are provided for the individual
and/or family
2. Yes licensed residential services, but not family resource service
_____ 3. Yes family resource services but not residential services
4. No
9. Don't know, no response, unclear response
17. Does your agency provide representative payee, ISO (intermediate service organization), payment agent, or benefits counseling services for the individual or his/her family?
1. Yes, the agency provides at least one of these services for the individual or his family
_____ 2. No
9. Don't know, no response, unclear response
18. Does the individual attend regularly scheduled social recreational events and services sponsored by your agency, which may or may not include self-advocacy events? Regularly scheduled events are defined as events scheduled at least once every two months.
8. Not applicable. The agency does not offer regularly scheduled social and
recreational events
2. Yes, the individual attends these events regularly
_____ 3. Yes, the individual sometimes attends these events
4. No, the events are available but the individual does not attend
9. Don't know, no response, unclear response
19. Does the individual receive transportation to and from work or day program by your agency?
1. Yes, always or most of the time
_____ 2. Yes, at least sometimes
3. No
9. Don't know, no response, unclear response
20. Does the individual receive transportation to and from work or day program by family, friends and/or relatives?
1. Yes, always or most of the time
_____ 2. Yes, at least sometimes
3. No
9. Don't know, no response, unclear response
21. Does the individual utilize public transportation to and from work or day program? Public transportation includes bus, van service, taxi, trolley, subway, shared ride, and persons with disabilities (PWD) reduced fair shared ride in some rural counties.
1. Yes, always or most of the time
_____ 2. Yes, at least sometimes
3. No
9. Don't know, no response, unclear response
22. If public transportation resources could be used for the individual, does the program offer training in how to use public transportation or drivers education to individuals in the program?
1. Yes, program provides training on use of public transportation
_____ 2. Yes, program provides training on use of public transportation and drivers’ education
3. No
9. Don't know, no response, unclear response
23. What is the primary funding source for the work or day program services the individual receives from your agency? (Indicate one source only). Note: Most 05-06 Pilot recipients will be MH/MR base funded or be funded by OVR as a primary source.
15. Not applicable. Individual does not receive funding for services.
14. School district
13. Welfare to work
12. Federal or State demonstration grant
11. Social Security through a Ticket to Work Employment Network
10. PFDS Waiver
9. Consolidated Waiver
_____ 8. ICF/MR
7. MH/MR base funding
6. OVR
5. PA Career Link
4. United Way or other community funding source
3. Private funding by individual or family
2. Foundation or other third party funding source
1. Other
0. Don't know, no response, unclear response
If other, please specify: ______
24. If the individual has been, or is employed in the community where he/she is compensated at or above minimum wage during the past year, what is the duration of the person's most current job?
0. Not applicable. Individual is not employed or is employed at below minimum wage
1. less than one month 10. nine months
2. one month 11. ten months
3. two months 12. eleven months
_____ 4. three months 13. twelve months
5. four months 14. thirteen months to 24 months
6. five months 15. 25 months to 36 months
7. six months 16. 37 months or more
8. seven months 17. Don't know, no response, unclear response
9. eight months
25. If the individual has been or is employed and receiving at least minimum wage in the community during the last 12 months, approximately how many average hours did/does the person work a week? (Enter approximate number of average weekly estimated hours rounded to the nearest whole number.)
1. Not applicable. Individual did not work at minimum wage in the last year
2. 5 hours or fewer hours a week
3. 6 to 10 hours
4. 11 to 15 hours
5. 16 to 20 hours
_____ 6. 21 to 25 hours
7. 26 to 30 hours
8. 31 to 40 hours
9. 41 to 45 hours
10. 46 to 50 hours
11. Don't know, no response, unclear response
26. If the individual is receiving supported employment service or has received supported employment over the last year, approximately how many average hours of supported employment job coaching does/did the individual receive per month over this 12 month period?