Page 221 - QAP Manual 2020

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

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

Section II: Survey With Person Receiving Services or with Proxy

Respondents

Please review Section I, Question 58. Please make sure you have answered that
STOP
question before proceeding.

TOP
General Instructions:

• If at all possible, ask the person receiving services these Section II questions. If the person is
unwilling or unable to complete this section, other respondents may be surveyed (family,
advocate, staff—but not the case manager or service coordinator). If the individual did not
complete Section I or if you believe that s/he did not understand the questions and/or did
not answer consistently, do not ask the individual the Section II questions—only ask the
proxy respondent(s). Proxy respondents must be knowledgeable in the areas below (they
should know the person well and have frequent contact with him/her). Use the alternate
wording provided when questioning proxy respondents (e.g., “Did this person…?”).
• For all questions, indicate who the respondent was; please check only one respondent for
each question.

• If both the individual and the proxy respondent contributed to the answer, and there is
agreement between the two, check “individual” as the respondent.

• If there is disagreement between the individual and the proxy respondent, you may need to
ask follow-up questions to determine the most valid response.

Ask the person if they wish to continue with the questions, or if they would like to take a
short break.

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