Page 184 - QAP Manual 2020

NCI™ ADULT IN-PERSON SURVEY (IPS) 2020-21
□ 1. No Number of N/A □ 1. No □ 1. No
BI-45 Unpaid activity in a community-based
setting □ 2. Yes hours spent at □ 2. Yes □ 2. Yes
□ 99. Don’t activity in □ 99. Don’t know □ 99. Don’t
(e.g., volunteer activities, skills training, typical two-
community supports) know week period: know
If the person does more than one activity of __ __ __
this type, please refer to the activity at which
the person has spent the most time in the
past two weeks.
□ 1. No Number of HOURLY WAGE □ 1. No
BI-46 Paid work in a community business N/A
that primarily hires people with disabilities □ 2. Yes hours for which $ __ __ . __ __/hr □ 2. Yes
□ 99. Don’t person is paid □ 99. Don’t know
In this job, the employees with disabilities in typical two-
interact with the non-disabled population; know week period:
this job is NOT in a traditional work program __ __ __
and is NOT an enclave. Examples include
bakeries, carwashes, thrift stores, etc.
If the person does more than one activity of
this type, please refer to the activity at which
the person has spent the most time in the
past two weeks.

□ 1. No Number of TOTAL WAGES N/A N/A
BI-47 Paid work performed in a facility-
based setting □ 2. Yes hours for which EARNED IN TYPICAL
□ 99. Don’t person is paid TWO-WEEK PERIOD
(e.g., traditional work program or work in typical two- $_ __ __ . __ __
activity center; the location has been know week period:
developed specifically to provide work activity __ __ __
exclusively for people with disabilities and
people may be paid sub-minimum wage.)
If the person does more than one activity of
this type, please refer to the activity at which
the person has spent the most time in the
past two weeks.

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