Page 267 - QAP Manual 2020

Pre-Survey

Q# Q Intent Other Notes
A Name(s) of the person(s) Provides a point of contact in case additional
completing this form information is needed on the Pre-Survey
and/or person to be surveyed
B Person to be surveyed Provides contact and address information for
the person to be surveyed

C Legal guardian information, Provides name and contact information for Reminder: Surveyors should know the state’s
if applicable the guardian/conservator requirements related to contacting a person’s
guardian or conservator if the person has one.
Requirements and protocols vary by state.
D Approval requirements and Reminder to surveyors to comply with state-
procedures specific consent requirements; at minimum,
all surveyors must inform the individual that
the survey is voluntary

PS-1 Contact Provides contact information for the person
who can help set up the meeting time and
supply information on the person’s need for
support, assistance, and/or accommodations
during the meeting
PS-2 Case Manager/Service Name and contact information of the case Insert name in questions: Q33, Q34, Q69
Coordinator manager/service coordinator

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