Page 165 - QAP Manual 2020

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

PS-3 Person who can provide information about this individual’s employment

Please indicate the person (e.g., Job Coach, Case Manager) who can provide the most accurate
information about this person’s employment, such as hours worked and wages earned. This
 information is needed for Questions BI-43 - BI-48 in the Background Information Section.

Name Relationship

Email Phone

PS-4 Proxy Respondents

If you believe this person may be unable or unwilling to complete Section II of the survey, please
indicate the name(s) and number(s) of others who know him or her well and could respond on his/her
behalf. Family members, guardians/conservators, friends, and staff may respond; case managers
and/or service coordinators may not respond.

Name 1: Relationship

Email Phone

Name 2: Relationship

Email Phone

PS-5 Living Arrangement

Please indicate who this person lives with.
 This should be referenced when asking Question 78 and 79.

□ 1. Lives alone
□ 2. Lives with parent/relatives
□ 3. Lives in large residential care facility

□ 4. Lives in shared house or apartment
□ 5. Lives with partner, spouse and/or children

If applicable, provide first names of roommates or housemates:

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