Page 247 - QAP Manual 2020

2. PROXY ALLOWED During COVID time, did any of these happen... (surveyor read list and
check all that apply)
Other respondent: During COVID time, did any of the following things happen to this person? Please
read response options about the experience of the person receiving services.
Respondent: ( ) 1-individual ( ) 2-family/friend ( ) 3-staff ( ) 4-other

□ 1. Did you (/this person) move, or change where you live?
□ 2. (If you did not move) Were there changes in your (/this person’s) in-home supports?
For example, did you (/this person) get fewer or more supports in the home, or did the
in-home supports stop?
□ 3. Did you (/this person) stop going in-person to day program, workshop, or other
unpaid day/community activity?

□ 4. Did you (/this person) go fewer hours to day program, workshop or other unpaid
day/community activity?
□ 5. Did you (/this person) stop working at a paid job in the community?
□ 6. Did you (/this person) work fewer hours at a paid job in the community?
□ 7. Did you (/this person) see family and friends who don’t live with you (/him or her)
less often or stop seeing them in-person?

□ 8. Did you (/this person) go into the community (stores, restaurants, theaters, etc.) less
often or stop going?
□ 9. Did you (/this person) stop going to school in-person?
□ 10. Did something else change about your (/this person’s) daily life? (describe
___________________)
□ 98. None of the above - daily life did not change because of the coronavirus

□ 99. Don’t know, unclear response