Page 244 - QAP Manual 2020

1. Person’s home
2. Person’s workplace

3. Provider agency (e.g., provider agency office; not a home or workplace)
4. Public place
5. Other:_____________________

I-4 What is your job title/relationship to the State agency (or County agency if applicable)?
If there is more than one surveyor, check ALL THAT APPLY. If a surveyor has more than one role, select
the principal role for the state agency.

1. Quality assurance staff
2. Case manager/service coordinator
3. Contractor or consultant
4. Person receiving services/self-advocate
5. Parent/family member/guardian of a person receiving services

6. Student
7. Interested citizen (not a family member or provider)
8. Other:_________________________________________

I-5 Did you know/had you met the individual prior to conducting this survey?

□ 1. No
□ 2. Yes
□ 3. Not sure

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