Page 159 - QAP Manual 2020

Questions?
Contact Name
Contact Email
Contact Phone

IN-PERSON SURVEY (IPS) 2020-21
Previously known as the Adult Consumer Survey (ACS)

SC-1 Survey Code:_______________________________

Note: This code should be provided by the state project coordinator and is for data analysis purposes
only. A unique survey code should be assigned to each person. Do NOT use a number that could
possibly identify the person (for example, do not use social security numbers).

SC-2 Survey Status

If the survey was not conducted, please enter the reason why [CHECK ONE]:

□ 1. Contact information is incorrect
□ 2. Contact information is correct, but the person could not be reached
□ 3. Refused by individual receiving supports
□ 4. Refused by guardian/conservator and/or parent
□ 5. Deceased

□ 6. Person is not receiving services
□ 7. Face to Face survey is not possible and there are technology-related barriers to remote
survey → Go to Question SC-3
□ 8. Other reason survey could not be conducted
_____________________________________

SC-3 Technology

If the survey was not conducted due to barriers/challenges related to technology, what was the
barrier/challenge [CHECK ALL THAT APPLY]:

□ 1. Does not have access to internet
□ 2. Does not have access to computer
□ 3. Does not have access to webcam
□ 4. Does not have support needed to participate in videoconference
□ 5. Does not have access to phone or phone plan
□ 6. Other tech-related reason ______________________________________________

©2020 National Association of State Directors of Developmental Disabilities Services and Human Services Research
Institute. All rights reserved. Permission to use or reproduce portions of this document is granted for purposes of the
National Core Indicators (NCI) only. For other purposes, permission must be requested in writing from the authors.