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 19

11/29/1989

: Table 19

Personal AttendantsIf one or more of the self-care, mobility, communication, use of assistive devices activities require help/supervision: Who is person that helps: __________ (write-in) Is person paid to help with these things is it part of their job: yes/no Frequency of services in past month
Household Chores/ Home-Delivered MealsIf these activities are required (limitations in independent living): Who is the person who (helps with cleaning/brings in your meals)? __________ (write-in) Is person paid to help with these things is it part of their job: yes/no Frequency of services in past month
Home Health Aide/ Visiting Nurse/ Occupation and Physical TherapyHas home health aide/visiting nurse come to person's residence in past month to change dressing, take blood pressure, etc.? yes/no Frequency in past month Has physical/occupational therapist come to person's residence to provide therapy in past month? yes/no Frequency in past month
Respite CareHas someone other than friends/family members cared for person in past 6 months in order to provide primary informal caregiver a break: yes/no Frequency in past 6 months Usual length of breaks Location: sample member's residence, day care facility, other facility, other __________ (specify)
Early Intervention (For Children 0-3 Years)Received service: yes/no Frequency
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 ServicesFor each service: very satisfied, satisfied, neither satisfied or dissatisfied, dissatisfied, very dissatisfied Reasons for dissatisfaction: Receives too little/too much Not appropriate to needs Not reliable Not timely Too expensive Problem with provider's attitude Other __________ (specify)