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 21

11/29/1989

: Table 21

NHIS CoreNumber of persons in household (H.H.) Relationship of people to each other
Added Questions for NHIS "Special Places"2Any persons paid to live in H.H. as staff: yes/no Any persons who live in H.H. and rent rooms to others (roomers/boarders): yes/no For facilities with <15 people, characteristics of residents: Gender Age Disability status Facilities with >15 people: Demographic averages
Services Provided in ResidenceServices: Counseling/supervision (round-the-clock part-time) Meals Laundry/housecleaning Personal care assistance Medical/nursing assistance Day activity (See Social/Psychological Services Section)
Public/Private OperationIndividual/family/partnership, public agency, private agency If public: state, local, county Name of agency __________ If private: religious, not-for-profit, for-profit Licensed/certified by state, county, local agency Name of agency __________
Group Home Staff--Asked of Staff (Questions for Large Institutions May Be Based On NMES)Number of staff living here during the week Number living here on any given day Number working here during the week Number involved with supervision of residents Specific duties Average hours worked per week Average hours worked per week in each of the following: Administration Maintenance/housekeeping Education/day programming Medical/nursing services Other therapeutic services
Payment for ServicesWho is expected to pay: Sample member/family Medicare Medicaid Veteran's benefits Private insurance State/local agency Other No cost to sample member/family/third party payor Any costs paid by sample member/family Amount paid last month (nonreimbursable) by sample member/family
Satisfaction with ServicesVery satisfied, satisfied, neither satisfied or dissatisfied, dissatisfied, very dissatisfied Reasons for dissatisfaction: Not appropriate to needs Cost Roommate conflicts Staff conflicts Not convenient (transportation/other places) Not attractive/sanitary/safe Neighborhood not safe
Interviewer Observation of EnvironmentNumber of bedrooms (separate or not), number of public rooms, nature of neighborhood, external signs of "group home", evidence of health/safety problems
Choices in Residential ServicesCovered in Self-Direction