Page 201 - QAP Manual 2020

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

CA-1. Are there staff (or a family member) at your home where you live who
speak your preferred language?
□ 2. Yes
□ 3. Sometimes

□ 1. No
□ 99. Don’t know, no response, unclear response, or staff do not come
into your home

4. Do people let you know before they come into your home? (Do they
ring the doorbell or knock first and wait for an answer?)
Do not include people who live in the home. Include staff who have keys (i.e., if
they knock, come in only when scheduled or expected).

□ 2. Yes

□ 3. Sometimes
□ 1. No
□ 99. Don’t know, no response, unclear response, or people do not come
into your home

5. Do people let you know before coming into your bedroom?

□ 2. Yes
□ 3. Sometimes
□ 1. No
□ 99. Don’t know, no response, unclear response, or people do not come
into your bedroom

6. Do you have a place to be alone in your home? (Can you have time to
yourself?)

□ 2. Yes
□ 1. No
□ 99. Don’t know, no response, unclear response

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