Iowa Participant Experience Survey
Member Fact Sheet

Interview Date:«SurveyDate» / Interviewer:«Interviewer»
Interview Time: / StateID:«StateID»
Member Name: / «Member» / Enrolled For: «Program»
Street Address: / «cmr_Address1»
«cmr_Address2» / Home Phone: / «cmr_Phone»
City: / «cmr_City» / Cell Phone:
Parent: / «ParentName» / Phone: / «ParentPhone»
Guardian: / «GuardianName» / Phone: / «GuardianPhone»
Notes: / «InterviewerNotes»
Setup Time: / Interview Tool: / «SurveyID»
Interview Time: / Tool Type: / «SurveyType»
Travel Time: / Interview Style: / «InterviewStyle»
Questions
Where
Follow-Up Requested: / 411(p. 4) /

I

/ 464.1(p. 10) /

III

/ 470(p. 12) /

III

412(p. 4) / I / 464.2(p. 10) / III / 473(p. 12) / III
430(p. 6) / II / 466(p. 11) / III / 475(p. 13) / III
458(p. 8) / III / 468(p. 11) / III / 476(p. 13) / III
462(p. 9) / III / 469(p. 12) / III / 479(p. 14) / III
463(p. 10) / III / 469.1(p. 12) / III / 481(p. 14) / III
other
Interviewer Concerns:

Consumer+SE.doc (rev. 7/15/09)Iowa Participant Experience Survey-1-

Member: «cmr_FName»«cmr_LName»

Module I: Participant-Centered Service Planning and Delivery
Desired Outcome: Services and supports are planned and effectively implemented in accordance with each participant’s unique needs, expressed preferences and decisions concerning his/her life in the community.

You currently receive «Svc1», «Svc2», «Svc3», «Svc4» services. The «Program» waiver/program funds these services. Before these services started, you should have received help with setting up the services. This help could have included identifying your needs, finding a service provider, or other types of assistance. Your «wrk_Title», «CaseWorker», should have helped you with this.

401.Do you feel you have been a part of planning your «Program» services?

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

402.Do your services include all the things you told your team you need and want?

Yes

No

Sometimes (Some of them)

I don’t know

I don’t remember

No/Unclear response

If the response is “no” explain:

403.Do you know you can change your services when you want to?

Yes

No

I don’t know

I don’t remember

No/Unclear response

404. If you want to change your services who would you talk to?
(check all that apply)

My «wrk_Title»

My Guardian

My family member (mom, dad, sibling, etc.)

My team

My service provider

Other

I don’t know

I don’t remember

No/Unclear response

Consumer+SE.doc (rev. 7/15/09)Iowa Participant Experience Survey-1-

Member: «cmr_FName»«cmr_LName»

405.If your needs have changed, did your services change to meet those needs?

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

N/A (Never Changed)

Skip Note: Skip question 406 & 407 for individuals who only receive Remedial Services.

406.Does your «wrk_Title», «wrk_FName», talk to you about how your services are going?

Note to Interviewer: Explain, such as what your needs are, if your providers are doing what they should, etc.)

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

407.Is it easy to make contact with your «wrk_Title», «wrk_FName»?

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

N/A (Never Tried)

If the response is “no” or “sometimes” ask them to explain why:

408.When your team came together, they also talked about who would provide your services and what services you would receive. You receive:

  • «Units1» hours of «Svc1» services from «Provid1»
  • «Units2» hours of «Svc2» services from «Provid2»
  • «Units3» hours of «Svc3» services from «Provid3»
  • «Units4» hours of «Svc4» services from «Provid4»

408.1Did you decide to use this/these provider(s)?

Yes – Skip to Q.409

No

I don’t know – Skip to Q.409

I don’t remember – Skip to Q.409

No/Unclear response – Skip to Q.409

408.2 Who decided that you would use this/these provider(s)?
(check all that apply)

I did

My «wrk_Title»

My guardian

My family member (Mom, dad, etc.)

My team

Court Ordered

I don’t know

I don’t remember

No/Unclear response

409.Were other agencies talked about before «Provid1», «Provid2», «Provid3», «Provid4» was/were chosen?

Yes

No

I don’t know

I don’t remember

No/Unclear response

Note to Interviewer: (Below) name the services and related agency consumer is receiving services from (individually); record each answer separately.

  1. Are you using your approved services?

Note to Interviewer: Services cannot exceed monthly limits, yearly limits, etc.

410.1 / 410.2 / 410.3 / 410.4
Service: «Svc1» / Service: «Svc2» / Service: «Svc3» / Service: «Svc4»
Units: «Units1» / Units: «Units2» / Units: «Units3» / Units: «Units4»
Agency: «Provid1» / Agency: «Provid2» / Agency: «Provid3» / Agency: «Provid4»
Yes / Yes / Yes / Yes / Skip to Q.412
No / No / No / No
I don’t know / I don’t know / I don’t know / I don’t know / Skip to Q.412
I don’t remember / I don’t remember / I don’t remember / I don’t remember / Skip to Q.412
No/Unclear response / No/Unclear response / No/Unclear response / No/Unclear response / Skip to Q.412
If no, indicate why not being used: / If no, indicate why not being used: / If no, indicate why not being used: / If no, indicate why not being used:

411.Have you told anyone on your team that you aren’t receiving these service(s)?

Yes

No [Flag to CMonly current or unresolved issues]

I don’t know [Flag to CMonly current or unresolved issues]

I don’t remember [Flag to CMonly current or unresolved issues]

No/Unclear response [Flag to CMonly current or unresolved issues]

Skip Note: Skipquestion 412 for individuals who only receive HDM, PERS,
HVM, Assistive devices, or specialized medical equipment.

412.Does your staff spend all the time with you that they are suppose to?

Note to Interviewer: You may need to give an example from the plan on how much time the consumer is suppose to receive for the service

Yes

No [Flag to CMonly current or unresolved issues]

Sometimes [Flag to CMonly current or unresolved issues]

I don’t know

No/Unclear response

If the response is “no” or “sometimes” ask them to explain:

Skip Note: Skip question 413 for individuals who receive only CMH, RSP or Hab.

413.Has your «wrk_Title» talked to you about the Consumer Choices Option?

Yes

No

Unsure

No/Unclear response

Consumer+SE.doc (rev. 7/15/09)Iowa Participant Experience Survey-1-

Member: «cmr_FName»«cmr_LName»

Module II: Provider Capacity and Capabilities
Desired Outcome: There are sufficient HCBS providers and they possess and demonstrate the capability to effectively serve participants.

I’d like to talk more about your service provider(s), «Provid1», «Provid2», «Provid3», «Provid4». It’s important that the people and agencies that provide your services are well trained and do a good job for you.

Skip Note: Skipquestions 426 and 427 for individuals who only receive HDM, PERS, HVM, Assistive devices, or specialized medical equipment.

426.Do all your staff know how to help you?

Yes

No

Sometimes (Some of them)

I don’t know

No/Unclear response

If the response is “no” or “sometimes” ask consumer to explain, and identify staff and provider:

427.Are there things your staff could do better to help you?

Yes

No

Sometimes

I don’t know

No/Unclear response

If the response is “yes” or “sometimes” ask consumer to explain, and identify staff and provider:

Skip Note: Skipquestions 428-431 for individuals who only receive HDM, PERS, HVM, Assistive devices, or specialized medical equipment.

428.Do any of your staff do things that you don’t like when they are working with you or for you?

Yes

No – Skip to Q.432

Sometimes (Some of them)

I don’t know – Skip to Q.432

I don’t remember – Skip to Q.432

No/Unclear response – Skip to Q.432

If the response is “yes” or “sometimes” ask consumer to explain, and identify staff and provider:

429.Have you told anyone on your team that you didn’t like that?

Yes

No – Skip to Q.432

I don’t know – Skip to Q.432

I don’t remember – Skip to Q.432

No/Unclear response – Skip to Q.432

430.Did anything change when you told this person?

Yes

No – Skip to Q.432 [Flag to CM only current or unresolved issues]

Somewhat

I don’t know – Skip to Q.432

I don’t remember – Skip to Q.432

No/Unclear response – Skip to Q.432

431.Were you happy with the changes?

Yes

No

Somewhat

I don’t know

I don’t remember

No/Unclear response

Note to Interviewer: You may need to explain service provider is specific to the provider agency and not employees of the agency.

432.Have you had to change a service provider/agency that you were working with?

Yes

No – Skip to Q.451

I don’t know – Skip to Q.451

I don’t remember – Skip to Q.451

No/Unclear response – Skip to Q.451

433.Were you given a list or told the names of different service providers you could use?

Yes

No

I don’t know

I don’t remember

No/Unclear response

Consumer+SE.doc (rev. 7/15/09)Iowa Participant Experience Survey-1-

Member: «cmr_FName»«cmr_LName»

Module III: Participant Safeguards
Desired Outcome: Participants are safe and secure in their homes and communities, taking into account their informed and expressed choices.

I want to talk to you now about health and safety. It is important that all of us are healthy, both physically and emotionally. It is also important that we are safe. Since you use «Program»services, your «wrk_Title», and other people involved in your life may have talked about your health and safety. We call this using a team to help identify health and safety needs.

First, I’d like to talk to you about your physical health…

451.Did you and your team talk about health issues when your plan was being developed?

Yes

No

I don’t know

I don’t remember

No/Unclear response

452.Do you feel you have any health issues?

Yes

No –Skip toQ.454

Sometimes

I don’t know –Skip to Q.454

I don’t remember –Skip to Q.454

No/Unclear response –Skip to Q.454

If “yes” or “sometimes” ask consumer to explain:

453.Do the services you receive help with your health needs?

Yes

No

I don’t know

I don’t remember

No/Unclear response

If “yes” or “no” explained, record response:

454.Do you take any medications?

Yes

No – Skip to Q.459

Sometimes

I don’t know – Skip to Q.459

I don’t remember – Skip to Q.459

No/Unclear response – Skip to Q.459

455.Do you feel the medications are helping you?

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

456.Do you have someone to talk to if you have questions about your medication?

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

457.Does «Provid1», or «Provid2», or «Provid3», or «Provid4» staff help you with your medicine, including getting it from the pharmacy, setting up your medication, giving you your medicine, or checking that you have taken it?

Yes

No –Skip to Q.459

Sometimes

I don’t know – Skip to Q.459

I don’t remember – Skip to Q.459

No/Unclear response – Skip to Q.459

458.In the past 12 months, have you gone without your medicine because staff didn’t help you?

Yes [Flag to CMonly current or unresolved issues]

No

I don’t know

I don’t remember

No/Unclear response

If “yes,” document who that person was and agency that person worked for:

Now, I want to talk to you about your safety.

459.Did you and your team talk about safety issues such as fire, tornado, etc., when your plan was being developed?

Yes

No

I don’t know

I don’t remember

No/Unclear response

460.Do you feel you have any safety issues?

Note to Interviewer: Give examples such as getting in and out of the house by themselves, falling, being alone, issues with roommates, staff, etc.

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

If “yes” or “sometimes,” explain:

461.Do your services help you stay safe?

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

If “no,” explain:

Skip Note: Skip question 462 if the consumer lives by him/herself or with his/her parents.

462.Do you feel safe with the people you live with?

Yes

No [Flag to CMonly current or unresolved issues]

Sometimes [Flag to CMonly current or unresolved issues]

I don’t know

I don’t remember

No/Unclear response

If “no” or “sometimes,” explain:

463.Do you feel safe where you live?

Note to Interviewer: Give examples such as their house, their community, etc.

Yes

No [Flag to CMonly current or unresolved issues]

Sometimes [Flag to CMonly current or unresolved issues]

I don’t know

I don’t remember

No/Unclear response

If “no” or “sometimes,” explain:

464.Do you need any special equipment or changes to your home or vehicle to make your life easier or safer?

Note to Interviewer: May need to give examples such as ramps, low grade carpet, etc.

Yes

No – Skip to Q.465

I don’t know – Skip to Q.465

I don’t remember – Skip to Q.465

No/Unclear response – Skip to Q.465

If “yes,” explain:

464.1 Have you told anyone on your team about this?

Yes

No – Skip to Q.465 [Flag to CMonly current or unresolved issues]

I don’t know – Skip to Q.465 [Flag to CMonly current or unresolved issues]

I don’t remember – Skip to Q.465 [Flag to CMonly current or unresolved issues]

No/Unclear response – Skip to Q.465 [Flag to CMonly current or unresolved issues]

464.2 Did this person help you?

Yes

No [Flag to CMonly current or unresolved issues]

I don’t know [Flag to CMonly current or unresolved issues]

I don’t remember [Flag to CMonly current or unresolved issues]

No/Unclear response [Flag to CMonly current or unresolved issues]

465.Is there any place you go that you don’t feel safe such as work, school, restaurants, stores, or other community areas?

Yes

No – Skip to Q.467

Sometimes

I don’t know – Skip to Q.467

I don’t remember – Skip to Q.467

No/Unclear response – Skip to Q.467

If “yes” or “sometimes,” explain:

466.Have you told anyone on your team you don’t feel safe there?

Yes

No [Flag to CMonly current or unresolved issues]

I don’t know

I don’t remember

No/Unclear response

467.There are different ways to calm a person down with restraint. Some of the ways include giving them medicine, a shot, being held down by another person, or being strapped down. Has this happened to you in the past two years?

Yes

No – Skip to Q.470

I don’t know – Skip to Q.470

I don’t remember – Skip to Q.470

No/Unclear response –Skip to Q.470

If “yes,” document who, when and circumstances:

468.Have you told anyone on your team that this happened?

Yes

No – Skip to Q.470 [Flag to CMonly current or unresolved issues]

I don’t know – Skip to Q.470 [Flag to CMonly current or unresolved issues]

I don’t remember – Skip to Q.470 [Flag to CMonly current or unresolved issues]

No/Unclear response – Skip to Q.470 [Flag to CMonly current or unresolved issues]

469.Has a plan been written telling others how to help you if you become upset?

Yes

No – Skip to Q.470 [Flag to CMonly current or unresolved issues]

I don’t know – Skip to Q.470 [Flag to CMonly current or unresolved issues]

I don’t remember – Skip to Q.470 [Flag to CMonly current or unresolved issues]

No/Unclear response – Skip to Q.470 [Flag to CMonly current or unresolved issues]

469.1 Does the plan work for you?

Yes

No [Flag to CMonly current or unresolved issues]

Sometimes [Flag to CMonly current or unresolved issues]

I don’t know [Flag to CMonly current or unresolved issues]

I don’t remember [Flag to CMonly current or unresolved issues]

No/Unclear response [Flag to CMonly current or unresolved issues]

Have not had to use the plan

470.Has anyone hit or hurt you in any way, in the past two years?

Yes[Flag to CMonly current or unresolved issues]
[Flag to DHS/Protective Servicesonly current or unresolved issues]

No – Skipto Q.473

I don’t know – Skip to Q.473

I don’t remember – Skip to Q.473

No/Unclear response – Skip to Q.473

If “yes,” document who and when:

471.Did you tell someone this happened?

Yes

No – Skip to Q.473

I don’t know – Skip to Q.473

I don’t remember – Skip to Q.473

No/Unclear response –Skip to Q.473

472.Did it stop after you told this person?

Yes

No

I don’t know

I don’t remember

No/Unclear response

473.Do you know what to do if someone is hurting you?

Yes

No [Flag to CM]

I don’t know [Flag to CM]

I don’t remember [Flag to CM]

No/Unclear response [Flag to CM]

Module IV: Participant Rights and Responsibilities
Desired Outcome: Participants receive support to exercise their rights and in accepting personal responsibilities.

Because you are using government-funded services, it is important that your rights are protected. These rights include things such as feeling free to let staff know how services are going, being treated with respect, and being involved in choosing activities during service.

501.Does anyone talk to you about your rights?

Yes

No

I don’t know

I don’t remember

No/Unclear response

502.Do you feel you understand your rights?

Yes – Skip to Q.507

No

I don’t know

I don’t remember

No/Unclear response

503.Does someone help you if you don’t understand your rights?

Note to Interviewer: Give examples such as staff, guardian(s), family member(s), or friends, etc.

Yes

No – Skip to Q.507

Sometimes

I don’t know

I don’t remember

No/Unclear response

Skip Note: If Case Manager indicates in Face Sheet that consumer has a guardian, then go to Q. 504; if no guardian, skip to Q. 507. If consumer is under 18 years of age, skip to Q. 507.

504.Does this person help you make decisions about your life?

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

505.Do you agree with the decisions people make about your life?

Yes – Skip to Q.507

No

Sometimes

I don’t know – Skip to Q.507

I don’t remember – Skip to Q.507

No/Unclear response – Skip to Q.507

506.Is there someone you can talk to about this?

Yes

No

Sometimes

I don’t know

I don’t remember

No/Unclear response

Skip Note: Skip questions 507-509 for individuals who only receive HDM, PERS, HVM, Assistive devices, or specialized medical equipment.

507.When a staff person is working with you, they should respect your rights. Staff can only limit rights if you agree to that. Has staff stopped you from doing something that you wanted to do?

Yes

No – Skip to Q.510

Sometimes

I don’t know – Skip to Q.510

I don’t remember – Skip to Q.510

No/Unclear response – Skip to Q.510

508.Have you told anyone on your team that this happened?

Yes

No – Skip to Q.510

I don’t know – Skip to Q.510

I don’t remember – Skip to Q.510

No/Unclear response – Skip to Q.510

509.Did this person help you?

Yes

No

Somewhat

I don’t know

I don’t remember

No/Unclear response

510.Did you know you can look at your service file whenever you want?

Note to Interviewer: If necessary, explain what the service file is

Yes

No –Skip to Q.513

I don’t know

I don’t remember

No/Unclear response

511.Have you asked to look at your service file or notebook?

Yes

No – Skip to Q.513

I don’t know – Skip to Q.513

I don’t remember – Skip to Q.513

No/Unclear response – Skip to Q.513

512.Did you get to look at it when you asked?

Yes

No

I don’t know

I don’t remember

No/Unclear response

513.Has anyone explained to you how to make a complaint regarding your services?