Iowa Participant Experience Survey
Member Fact Sheet
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) / III430(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 DeliveryDesired 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.
- Are you using your approved services?
Note to Interviewer: Services cannot exceed monthly limits, yearly limits, etc.
410.1 / 410.2 / 410.3 / 410.4Service: «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 CapabilitiesDesired 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 SafeguardsDesired 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 ResponsibilitiesDesired 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?