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Quality Assurance Survey: Guardian
This survey is to be completed by the individual receiving services from Homeplace Support Services, assisted, if necessary, by a family member/legal guardian or residential provider staff. The survey is written as if it is being answered by the individual, regardless of who reads the statements to the individual or assists them in responding. If you are assisting the individual, please think in terms of the individual’s reaction, not your own experience or from your point of view. The results of this survey are confidential.
Your responses are anonymous and important to our continued work to improve the quality of services that Homeplace provides. We appreciate your participation and thank you for your time!
1. Homeplace staff are prompt, respectful, and courteous to me and/or to my family.
Yes
No
No Response
Comments:
2. Homeplace staff are responsive to my needs and concerns.
Yes
No
No Response
Comments:
3. I have input into who works with me?
Yes
No
No Response
Comments:
4 Staff provide me with choices and support me to make my own choices.
Yes
No
No Response
Comments:
5. Homeplace staff assist me in working towards goals that I have set for myself.
Yes
No
No Response
Comments:
6. Homeplace staff assist me to build relationships and friendships with the people I choose.
Yes
No
No Response
Comments:
7. Homeplace staff assist me in finding and accessing community resources and activities.
Yes
No
No Response
Comments:
8. I know who to talk to at Homeplace if I have a problem.
Yes
No
No Response
Comments:
9. Has anyone told you about your rights?
Yes
No
No Response
Comments:
10. Are you satisfied with the supports you are receiving from Homeplace?
Yes
No
No Response
Comments:
11. I like where I live.
Yes
No
No Response
Comments:
12. I feel free from abuse, neglect and exploitation.
Yes
No
No Response
Comments:
13. I like the people I live with and I am supported to choose who I live with.
Yes
No
No Response
Comments:
Comments / Future Question Suggestions
Please feel free to provide us with any additional comments or questions you would like to see added to future Quality Assurance Surveys.
Comments / Additional Questions
Comments
This field is for validation purposes and should be left unchanged.