Page 162 - QAP Manual 2020

NCI™ ADULT IN-PERSON SURVEY (IPS) 2020-21

Pre-Survey Background Section I Section II Surveyor
Form Info Feedback

Pre-Survey

ADVICE TO STATES. The Pre-Survey is intended to provide surveyors with the information they need to
schedule and conduct the face-to-face survey. The state should review this form and decide what
information will be provided to surveyors in advance (e.g., name, phone number, communication
needs, etc.), how the information will be gathered (e.g., service coordinators, databases, surveyors
etc.), and the administrative procedures (including informed consent) that must be followed when
arranging the face-to-face surveys.

None of the Pre-Survey information is submitted to HSRI. Actual procedures for using the Pre-Survey
Form should be determined by the state’s NCI coordinator and communicated to surveyors during
training. These procedures should also be communicated to HSRI.

ADVICE TO SURVEYORS. Please fill out and review as many of the Pre-Survey items as possible before
starting the face-to-face survey. Experience shows that using familiar names and terms helps the
respondent understand the questions being asked and facilitates the survey process. You can also use
this form to fill in blanks in Sections I and II of the survey: look for items marked with a  symbol.
Doing this prior to the face-to-face survey helps the conversation flow more smoothly.

Additional instructions regarding your state’s specific administrative procedures:

A. Person(s) completing this form

Name(s):

Date: _____/______/__________

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