Design for Survey of Persons with Mental Retardation and Developmental Disabilities: Summary of Recommendations for Survey Questions and Screening Criteria. Design for Survey of Persons with Mental Retardation and Developmental Disabilities: Summary of Recommendations for Survey Questions and Screening Criteria : Table 16

11/29/1989

: Table 16

Types of Equipment/AidsCurrent use: Manual wheelchair2 Motorized wheelchair2 Crutches2 Cane Walker Leg, back, or other type of brace Special shoes Artificial arm or leg Hearing aid Communication board2 Glasses or contact lenses Guide dog Respirator2 Kidney dialysis machine Feeding tube/machine2 Colostomy bag Urinary catheter Velcro fasteners or snaps Special dishes, cups, or utensils Other __________ (specify) None
Types of Residential ModificationsCurrently have in residence: Grab bars, and/or railings Shower seat or tub stool Hand held shower Raised toilet Portable toilet Specially equipped telephone (TTY, TTD, or amplified) Widened doorway Ramp Removed door sills/raised threshold Repositioned light switches, electrical outlets, and/or heating and cooling controls Adjusted height of cabinets/storage areas, counter tops, sinks Changed or repositioned sink or shower controls Faucets on side or front of sinks Lever-style door handles Emergency alarm Visual signals for telephone or door Braille or raised markings Accessible parking space or garage Sidewalks with curb cuts Other __________ (specify)
Payment ModeWho paid/is expected to pay for costs of services: sample member/family, Medicare/medicare HMO, Medicaid, Veteran's benefits, CHAMPUS/CHAMPVA, private insurance/non-Medicare HMO, other, no cost of sample member/family/third party Any costs incurred by sample member/family: yes/no Total paid by sample member/family excluding insurance paybacks
Satisfaction With Equipment/ ModificationsFor each service: satisfaction with availability of equipment, cost, way equipment works, adequacy of home modifications: Very satisfied Satisfied Neither satisfied or dissatisfied Dissatisfied Very dissatisfied