Page 238 - QAP Manual 2020

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

Self-Directed Supports Module

100. SURVEYOR: From Pre-Survey Form and Background Info: Does person use self-directed
supports?

PS-10 (Refer to PS-10 for terms the person may be familiar with.) See PS-10 and BI-62 to know if
 person is identified as using self-directed supports.
□ 2. Yes
□ 1. No →Leave 101-108 blank, answer 109 and 110 and complete the Surveyor
Feedback Sheet
□ 99. Don’t know →Leave 101-108 blank, answer 109 and 110 and complete the
Surveyor Feedback Sheet

101. Who makes decisions about how your budget for services is used?
Other Respondent: Who makes decisions about how this person’s budget for services is used?

Respondent: ( ) 1-individual ( ) 2-family/friend ( ) 3-staff ( ) 4-other

□ 1. Individual mostly controls/makes decisions
□ 2. Individual has input; family or friends also help with decisions
□ 3. Someone else makes decisions (family member or close friend)

□ 4. Decisions about what services are received are made by a case manager or another
professional employed by the state
□ 99. Don’t know, no response, unclear response

102. Do you participate in decisions about how to use your supports budget, hiring staff, or
managing the services you get? (Do you self-direct your supports?)
Other respondent: Do you and/or this person participate in decisions about supports budget,
hiring staff, or managing services?
Respondent: ( ) 1-individual ( ) 2-family/friend ( ) 3-staff ( ) 4-other

□ 2. Yes

□ 1. No →Leave 103-108 blank, answer 109 and 110 and complete the Surveyor
Feedback Sheet
□ 99. Don’t know, no response, unclear response →Leave 103-108 blank, answer 109
and 110 and complete the Surveyor Feedback Sheet

Questions 103-108 should only be asked if the person completing the section (individual with
disability or proxy) participates in decisions about supports budget, hiring, or managing their
services. If the person responding to the section does not participate in these decisions:
Surveyor, please end the face-to-face conversation, answer Question 109 and 110 and
complete the Surveyor Feedback Sheet that can be found after this section.

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