Page 164 - QAP Manual 2020

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

PS-1 Contact
Who should the surveyor call to arrange a face-to-face survey with this person (individual,
parent/guardian/conservator, day or residential program staff, etc.)?

Name

Relationship to Individual

Phone #1: Phone #2:

Email

Meeting Companion: Should a caregiver be present? We would like to conduct the face-to-face survey
with the individual alone, when appropriate. However, some individuals may feel uncomfortable with
strangers and some individuals may have medical, behavioral, or other reasons for supervision or
support from designated caregivers.

Do you recommend that a caregiver be present while this person is surveyed? ⃝ 2. Yes ⃝ 1. No

If yes, please explain:

Accommodations: Does this person need any accommodations? Examples: Communication – sign
language, communication device, voice amplifier, someone familiar with the person’s communication
style, interpreter if primary language is something other than English; Accessibility – transportation,
space issues; Other – medical, allergies
Please explain the arrangements needed for the face-to-face survey:

PS-2 Case Manager/Service Coordinator

What is the name and contact information of this person’s case manager/service coordinator?
 This should be referenced when asking Questions 40, 41, 42, and 87.
Name Phone:

Email: Cell Phone:

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