VERMONT CONSUMER SURVEY PROJECT
DEMOGRAPHIC SURVEY
1. Consumer Name 2. Agency Name ______
3. Date of Interview with Service Coordinator ______
4. Interviewer ______
6. If person was NOT scheduled for interview, check PRIMARY REASON why not
__1 Person’s choice – declined opportunity for interview
__2 Person out of town
__3 Person incapacitated/emotional difficulty/anxiety by person
__4 Agency decision – person has insufficient ability to reliably communicate to interview
__5 Agency scheduling oversight
__6 Guardian’s decision
__7 Don’t know
__8 Other (please specify): ______
GENERAL DEMOGRAPHICS
7. Gender __1 Male __2 Female
8. DOB / / 9. Age ______
mm dd yyyy
10. Race (CHECK ONE OR MORE RACES to indicate what the person considers him/herself to be)
__1 American Indian or Alaska Native
__2 Asian
__3 Black or African American
__4 Pacific Islander
__5 White
__6 Other Race not listed
__7 Don’t know
11. Is this person Spanish/Hispanic/Latino?
__1 No
__2 Yes
__3 Don’t know
12. Does this person have an appointed guardian? (CHECK ONE)
__1 No, person is legally competent adult independent of guardianship
__2 Yes, person has private guardian (including parent/relative or non-relative)
__3 Yes, person has public guardian (Guardianship Services Specialist)
__4 Don’t know
13. Does the person have a representative payee or financial guardian?
__1 No
__2 Yes
__3 Don’t know
This survey is based on an instrument developed by Susan L. Culbert and Sara N. Burchard, Psychology Department, University of Vermont, Burlington, VT 05405 (6/15/01).
Copyright © All rights reserved. No part of this instrument may be copied or reproduced in any form by any means without written permission of the authors.
Vermont Division of Disability and Aging Services, 103 South Main Street, Waterbury, VT 05671-1601 (6/1/04 – updated 6/1/05).
14. Marital Status
__1 Single, never married
__2 Married/Civil Union
__3 Single, married/Civil Union in past
__4 Don’t know
15. Does this person have any court-ordered restrictions (i.e., probation, parole, conditional re-entry, Act 248)?
__1 No
__2 Yes (please specify) ______
__3 Don’t know
16. Does the person have any family that is involved in his/her life?
__1 Yes
__2 No
__3 Don’t know
17. If NO, please check why not
__1 Family gone/no longer alive/whereabouts unknown
__2 Family’s choice not to be in touch
__3 Court-ordered restrictions
__4 Other (please specify) ______
__5 Don’t know
COMMUNICATION
18. What is the person’s primary language? (What language does he/she understand?)
__1 English
__2 Other (please specify) ______
19. What is the person’s primary means of expression? (CHECK ONE – most frequently used)
__1 Spoken
__2 Gestures/body language
__3 Sign language or finger spelling
__4 Communication aid/ device
__5 Other (please specify) ______
__6 Don’t know
20. Does this person have adequate, reliable speech, which is understood by others (including strangers) and
allows him/herself full expression?
__1 Yes (If “Yes”, skip to Q27)
__2 No
__3 Don’t know
21. Does this person have a communication expectation or outcome in his/her current ISA?
__1 Yes
__2 No
__3 Don’t know
22. Does this person communicate with people who are known and familiar to the person (e.g., people with
whom they live or work)?
__1 Yes
__2 No
__3 Don’t know
23. Does this person communicate with people who are unfamiliar to the person (e.g., people in stores, at the
bank, in restaurants)?
__1 Yes
__2 No
__3 Don’t know
24. Does this person communicate for a variety of purposes beyond basic wants and needs (e.g., social
interactions, sharing and getting information from others, turning down an offer)?
__1 Yes
__2 No
__3 Don’t know
25. Taking into consideration the person’s communication effectiveness, do you feel that within the past year
the person communicates:
__1 More effectively
__2 As effectively
__3 Less effectively
__4 Temporary change in the person’s health/medical status prevents fair assessment of
his/her communication effectiveness at this time
__5 Don’t know
26. What communication supports exist in the person’s life? Does the person have:
a. Consistent communication partners? __1 Yes __2 No __3 Don’t know
b. Support from his/her team? __1 Yes __2 No __3 Don’t know
c. Access to communication aids or devices __1 Yes __2 No __3 Don’t know
d. Availability of training for support people __1 Yes __2 No __3 Don’t know
e. Consultation or support from SLP
or someone with communication experience? __1 Yes __2 No __3 Don’t know
MEDICAL/HEALTH
27. How is this person currently labeled in his/her records? (Please check record for information)
__1 Does not have MR label
__2 Mild MR (317)
__3 Moderate MR (318.0)
__4 Severe MR (318.1)
__5 Profound MR (318.2)
__6 Don’t know or not available in records
28. What disabilities other than MR are noted in this person’s records? (CHECK ALL THAT APPLY)
__1 Mental illness/ psychiatric diagnosis (e.g. depression)
__2 Autism/Pervasive Developmental Disorders (PDD)
__3 Cerebral palsy
__4 Brain injury
__5 Seizure disorder/neurological problems
__6 Chemical dependency
__7 Vision impairment
__8 Hearing impairment
__9 Physical disability
__10 Communication disorder
__11 Alzheimer’s disease
__12 Down Syndrome
__13 Prader Willi Syndrome
__14 Other disability(ies) not listed (please specify) ______
__15 No known disability other than MR or not available in records
29. If this person has seizures, how often do they occur? (CHECK ONE)
__1 Less frequently than once/month
__2 At least once/month, but not once a week
__3 At least once/week or more frequently
__4 Don’t know or not available in records
__5 Not applicable – does not have seizures
30. How often does this person require medical care? (Medical care refers to care that must be performed or
delegated by a nurse or physician. Do not include medication administration) (CHECK ONE)
__1 Less frequently than once/month
__2 At least once/month, but not once a week
__3 At least once/week or more frequently
__4 Don’t know or not available in records
31. When was this person’s last physical exam? (Please check record for date)
__1 In the past year
__2 Over 1 year ago
__3 Don’t know or not available in records
32. When was this person’s last dentist visit? (Please check record for date) (If this person has no teeth, include
a physician’s gum check as a dental visit)
__1 In the last 6 months
__2 Over 6 months ago
__3 Don’t know or not available in records
33. How would you describe this person’s mobility? (CHECK ONE)
__1 Can move self around environment – walks (with or without aids) or uses wheelchair
__2 Non-ambulatory – needs assistance to move around environment
__3 Don’t know
34. How would you describe this person’s vision? (CHECK ONE)
__1 Sees well, with or without corrective lenses
__2 Vision problems limit activities, such as reading or travel
__3 Limited or no vision (legally blind)
__4 Don’t know
35. Is weight a concern for this person?
__1 Yes, person is overweight
__2 Yes, person is underweight
__3 No
__4 Don’t know
36. Does the person smoke or chew tobacco?
__1 Yes
__2 No
__3 Don’t know
37. How physically active is this person?
__1 Very physically active
__2 Moderately physically active
__3 Physically inactive
__4 Don’t know
BEHAVIORAL CHALLENGES
38. Does this person need support to prevent self-injury? (“Self-injury” refers to attempts to cause harm to one’s
own body, for example by hitting or biting self, banging head, scratching or puncturing skin.)
1 __ No 2 __ Yes 3 __ Don’t know
If “Yes”, how often does the person need support to manage this behavior? (CHECK ONE)
__1 Needs occasional support, less frequently than once a month
__2 At least once/month, but not once/week
__3 At least once/week or more frequently
__4 Don’t know or not applicable (no support needed)
39. Does this person need support to prevent disruptive behavior? (“Disruptive behavior” refers to emotional
outbursts that interfere with the activities of others, for example, by starting fights, laughing or crying
without apparent reason, yelling or screaming, cursing, throwing objects, or threatening violence.)
1 __ No 2 __ Yes 3 __ Don’t know
If “Yes”, how often does the person need support to manage this behavior? (CHECK ONE)
__1 Needs occasional support, less frequently than once a month
__2 At least once/month, but not once/week
__3 At least once/week or more frequently
__4 Don’t know or not applicable (no support needed)
40. Does this person need support to prevent uncooperative behavior? (“Uncooperative behavior” refers broadly
to externally-directed, defiant behavior, for example, refusing to attend school or work, breaking the rules,
taking other people’s property, or stealing.)
1 __ No 2 __ Yes 3 __ Don’t know
If “Yes”, how often does the person need support to manage this behavior? (CHECK ONE)
__1 Needs occasional support, less frequently than once a month
__2 At least once/month, but not once/week
__3 At least once/week or more frequently
__4 Don’t know or not applicable (no support needed)
RESIDENTIAL
41. What amount of PAID SUPPORT does this person receive at home? (CHECK ONE)
__1 24-hour on-site support and/or supervision (people living with, or being available in his/her home
during any hours that he/she is home)
__2 Daily on-site support (for a limited number of hours-per-day; not round-the-clock)
__3 Less frequent than daily support
__4 As needed visits and/or phone contact (e.g., intermittent contact, on-call only)
__5 None of the above (lives independently or with family without any paid in-home support)
__6 Don’t know
42. How would you categorize the place where this person lives? (CHECK ONE)
__1 Intermediate Care Facility (ICF/MR)
__2 Group living (group home)
__3 Staffed living (staffed apartment – usually agency owned or leased)
__4 Person’s own home or apartment
__5 Parents' or family member’s home
__6 Developmental home (shared living)
__7 Nursing home
__8 Residential Care Home (community care home)
__9 Other (please specify) ______
__10 Don’t know
43. Who own or leases the place where this person lives? (CHECK ONE)
__1 Family or guardian
__2 Individual or family with whom the person lives who is unrelated
__3 Provider agency/affiliate
__4 Person rents home (name is on the lease)
__5 Person owns home (name is on the title)
__6 Don't know
__7 Other (please specify) ______
44. Primary household composition (CHECK ONE that best describes the living situation)
__1 Lives alone
__2 Spouse/Civil Union
__3 Minor child(ren) only
__4 Biological/adoptive parent(s)
__5 Other relative(s) (e.g., sibling, grandparent)
__6 Non-related individual(s) (e.g., home provider, staff, other people with disabilities)
__7 Domestic Partner
__8 Other (please specify) ______
__9 Don’t know
45. Location of Residence:
__1 Residence is physically remote; not within walking distance to town or to public transportation
__2 Residence located within walking distance to town/city (within 1/2 mile)
__3 Residence centrally located within city, town, or village center (within block or so of downtown)
__4 Don’t know
46. How long has this person lived in his/her current home or with the same care giver/home provider?
(Don’t count moves with the same caregiver/home provider.)
__1 Less than 1 year
__2 1 – 2 years
__3 3 – 5 years
__4 >5 years
__5 Don’t know or not available in records
SERVICES
47. What PAID services and supports does this person currently receive? (Please check record for information)
a. Service Coordination/ Case Management __1 Yes __2 No __3 Don’t know
b. Employment Services – indiv. supported employment __1 Yes __2 No __3 Don’t know
c. Employment Services – group employment __1 Yes __2 No __3 Don’t know
(i.e., enclave or work crew)
d. Home Supports __1 Yes __2 No __3 Don’t know
e. Community Supports – individual __1 Yes __2 No __3 Don’t know
f. Community Supports – group __1 Yes __2 No __3 Don’t know
g. Clinical Services __1 Yes __2 No __3 Don’t know
h. Transportation __1 Yes __2 No __3 Don’t know
i. Family Supports – Respite/Flexible Family Funding __1 Yes __2 No __3 Don’t know
j. Other (please specify): ______1 Yes __2 No __3 Don’t know
48. What Developmental Services funding does the person have? (CHECK ALL THAT APPLY)
__1 Waiver (Home and Community-based Waiver)
__2 ICF/MR
__3 Vocation Grant (VR)
__4 Flexible Family Funding
__5 Fee-for-service (e.g., Targeted Case Management, PASARR)
__6 Don’t know
__7 Other (please specify) ______
Community Supports
49. Number of Individual Community Support hours per week ______
50. Number of Group Community Support hours per week ______
If the person gets Community Supports, what kinds of things does the person do (include volunteer activities)?
______
______
______
Work
51. Does the person have a job? __1 Yes __2 No __3 Don’t know
If the person has a job, where does he/she work (name of business) and what kinds of things does he/she do?
______
______
______
Features of Self-Management/Self-Determination
52. Does this person (or person’s family) currently use a self-managed support option?
(For example, the person or family manages some or all of their services – hires his/her own support workers
or providers who are paid through a fiscal intermediary or payroll service.)
__1 Yes, self-managed or shared-managed (agency and self)
__2 Yes, family-managed or shared-managed (agency and family)
__3 No, agency manages all the services
__4 Don’t know
53. Does this person have an individually negotiated budget? (Auto response based on funding – see Q48)
__1 Yes (includes all people receiving Waiver and/or Flexible Family Funding)
__2 No (includes all people receiving ICF/MR, Vocational Grant or Fee-for-service)
__3 Don’t know
54. Does this person currently have an Individual Support Agreement (ISA) or other personal-centered plan?
__1 Yes
__2 No (generally includes people getting Flexible Family Funding and/or Fee-for-service only)
__3 Don’t know
55. Does this person (or person’s family) currently use a fiscal intermediary, such as an Intermediary Service
Organization (ISO) or private payroll service?
__1 Yes
__2 No
__3 Don’t know
56. Does this person (or person’s family) currently use an independent support broker (ISB) or personal agency