MY INDIVIDUAL EXPERIENCE SURVEY

Question	Yes	No	Don't Know	Doesn't Apply
1. I don't have a job, but I have a place(s) to go during the day.	Yes	No	Don't Know	Doesn't Apply
2. If I want to, I can have a job.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
3. I go places like the bank, the grocery store, the mall, restaurants and the place where I go pray.	Yes	No	Don't Know	Doesn't Apply
4. I do things I want to do.	Yes	No	Don't Know	Doesn't Apply
5. I do things with others who live in my town.	Yes	No	Don't Know	Doesn't Apply
6. I have support to do the things I want to do in my community at the times I want to do them.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
7. I use my money the way I want.	Yes	No	Don't Know	Doesn't Apply
8. I can get my money when I need it.	Yes	No	Don't Know	Doesn't Apply
9. I have a phone I can use to call friends and family.	Yes	No	Don't Know	Doesn't Apply
10. I have any support I need to keep my assistive technology, phone and/or computer working well.	Yes	No	Don't Know	Doesn't Apply
11. I can use my books, phone, games, etc., when I want to.	Yes	No	Don't Know	Doesn't Apply
12. I can be alone if I want to be.	Yes	No	Don't Know	Doesn't Apply
13. My friends and I can be alone when we want to be.	Yes	No	Don't Know	Doesn't Apply
14. I am treated the way that I want to be.	Yes	No	Don't Know	Doesn't Apply
15. I feel safe around the staff that work with me.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
16. I take medicine that helps me control the way I act around others.	Yes	No	Don't Know	Doesn't Apply
17. I (or my guardian) talked with my doctor and gave the doctor an "okay" for me to take medicine for behavior.	Yes	No	Don't Know	Doesn't Apply
18. My medicine helps me to feel better.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
19. I choose my own services.	Yes	No	Don't Know	Doesn't Apply
20. I get to pick the provider I want for my services/supports.	Yes	No	Don't Know	Doesn't Apply
21. I pick the staff that helps me do things.	Yes	No	Don't Know	Doesn't Apply
22. I can get help, if I need it, to make decisions about my rights.	Yes	No	Don't Know	Doesn't Apply
23. I have say-so and control over my life.	Yes	No	Don't Know	Doesn't Apply
24. I choose what I do with my free time.	Yes	No	Don't Know	Doesn't Apply
25. I choose the staff who help me to do what I want in my free time.	Yes	No	Don't Know	Doesn't Apply
26. I can get food whenever I want it.	Yes	No	Don't Know	Doesn't Apply
27. I can have people visit me whenever I want.	Yes	No	Don't Know	Doesn't Apply
28. I am able to get around easily at my work or where I spend my day.	Yes	No	Don't Know	Doesn't Apply
29. Please share with us anything else you want to tell us about the services you get: Do not enter your name, Medicaid number, phone number or address.

Question	Yes	No	Don't Know	Doesn't Apply
1. I don't have a job, but I have a place(s) to go during the day.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
2. If I want to, I can have a job.	Yes	No	Don't Know	Doesn't Apply
3. I go places like the bank, the grocery store, the mall, restaurants and the place where I go to pray.	Yes	No	Don't Know	Doesn't Apply
4. I do things I want to do.	Yes	No	Don't Know	Doesn't Apply
5. I do things with others who live in my town.	Yes	No	Don't Know	Doesn't Apply
6. I have support to do the things I want to do in my community at the times I want to do them.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
7. I use my money the way I want.	Yes	No	Don't Know	Doesn't Apply
8. I can get my money when I need it.	Yes	No	Don't Know	Doesn't Apply
9. I have a phone I can use to call friends and family.	Yes	No	Don't Know	Doesn't Apply
10. I have any support I need to keep my assistive technology, phone and/or computer working well.	Yes	No	Don't Know	Doesn't Apply
11. I can use my books, phone, games, etc., when I want to.	Yes	No	Don't Know	Doesn't Apply
12. I can be alone if I want to be.	Yes	No	Don't Know	Doesn't Apply
13. I feel safe around the staff that work with me.	Yes	No	Don't Know	Doesn't Apply
14. I choose my own services.	Yes	No	Don't Know	Doesn't Apply
15. I get to pick the provider I want for my services/supports.	Yes	No	Don't Know	Doesn't Apply
16. I pick the staff that helps me do things.	Yes	No	Don't Know	Doesn't Apply
17. I can get help, if I need it, to make decisions about my rights.	Yes	No	Don't Know	Doesn't Apply
18. I have say-so and control over my life.	Yes	No	Don't Know	Doesn't Apply
19. I have a way to get to the places I want to go (car, bus, or other transportation).	Yes	No	Don't Know	Doesn't Apply
20. I have the help I need to use the services in my community (places to eat, places to shop, schools, gyms, bus, doctor's office).	Yes	No	Don't Know	Doesn't Apply
21. Please share with us anything else you want to tell us about the services you get: Do not enter your name, Medicaid number, phone number or address.

Question	Yes	No	Don't Know	Doesn't Apply
1. I don't have a job, but I have a place(s) to go during the day.	Yes	No	Don't Know	Doesn't Apply
2. If I want to, I can have a job.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
3. I go places like the bank, the grocery store, the mall, restaurants and the place where I go to pray.	Yes	No	Don't Know	Doesn't Apply
4. I have a way to get to the places I want to go (car, bus, or other transportation).	Yes	No	Don't Know	Doesn't Apply
5. I have the help I need to use the services in my community (places to eat, places to shop, schools, gyms, bus, doctor's office).	Yes	No	Don't Know	Doesn't Apply
6. My friends and I can be alone when we want to be.	Yes	No	Don't Know	Doesn't Apply
7. My friends can visit me any time that I want them to come.	Yes	No	Don't Know	Doesn't Apply
8. I do things I want to do.	Yes	No	Don't Know	Doesn't Apply
9. I do things with others who live in my town.	Yes	No	Don't Know	Doesn't Apply
10. I have support to do the things I want to do in my community at the times I want to do them.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
11. I use my money the way I want.	Yes	No	Don't Know	Doesn't Apply
12. I can get my money when I need it.	Yes	No	Don't Know	Doesn't Apply
13. I have a phone I can use to call friends and family.	Yes	No	Don't Know	Doesn't Apply
14. I have any support I need to keep my assistive technology, phone and/or computer working well.	Yes	No	Don't Know	Doesn't Apply
15. I can use my books, phone, games, etc., when I want to.	Yes	No	Don't Know	Doesn't Apply
16. I can be alone if I want to be.	Yes	No	Don't Know	Doesn't Apply
17. I am treated the way that I want to be.	Yes	No	Don't Know	Doesn't Apply
18. I feel safe around the staff that work with me.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
19. I take medicine that helps me control the way I act around others.	Yes	No	Don't Know	Doesn't Apply
20. I (or my guardian) talked with my doctor and gave the doctor an "okay" for me to take medicine for behavior.	Yes	No	Don't Know	Doesn't Apply
21. My medicine helps me to feel better.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
22. I choose my own services.	Yes	No	Don't Know	Doesn't Apply
23. I get to pick the provider I want for my services/supports.	Yes	No	Don't Know	Doesn't Apply
24. I pick the staff that helps me do things.	Yes	No	Don't Know	Doesn't Apply
25. I can get help, if I need it, to make decisions about my rights.	Yes	No	Don't Know	Doesn't Apply
26. I have say-so and control over my life.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
27. I picked the place where I live.	Yes	No	Don't Know	Doesn't Apply
28. I can talk on the phone and open mail or email without others having to be close by.	Yes	No	Don't Know	Doesn't Apply
29. Please share with us anything else you want to tell us about the services you get: Do not enter your name, Medicaid number, phone number or address.

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Section III: Setting Owned or Controlled by a Provider

You only need to fill out this section if you live in alterative family living or a group home.

Question	Yes	No	Don't Know	Doesn't Apply
1. Where I live, things get fixed when they are not working. Things like: Lights Toilets Heat Air Conditioning (AC) Smoke Detectors Stove or Oven Refrigerator	Yes	No	Don't Know	Doesn't Apply
2. My provider and I have a legal written agreement that spells out my rights and responsibilities for my home.	Yes	No	Don't Know	Doesn't Apply
3. I like where I live.	Yes	No	Don't Know	Doesn't Apply
4. I visited different places before I picked out my home.	Yes	No	Don't Know	Doesn't Apply
5. I have my own key to my house.	Yes	No	Don't Know	Doesn't Apply
6. My things are safe in my room.	Yes	No	Don't Know	Doesn't Apply
7. People knock on my door and ask before they come into my room.	Yes	No	Don't Know	Doesn't Apply
8. My bedroom and home look the way I want them to. (Pictures I like, a bedspread I like, things are where I want them, etc.)	Yes	No	Don't Know	Doesn't Apply
9. I asked for my own bedroom.	Yes	No	Don't Know	Doesn't Apply
10. I have my own bedroom. I do not share my room.	Yes	No	Don't Know	Doesn't Apply
11. I picked the person I share my room with.	Yes	No	Don't Know	Doesn't Apply
12. I can get food at home whenever I want it.	Yes	No	Don't Know	Doesn't Apply
13. I can have people visit me whenever I want.	Yes	No	Don't Know	Doesn't Apply
14. I choose the staff who help me to do what I want with my time.	Yes	No	Don't Know	Doesn't Apply
15. I choose what I do when I am not working or have extra time.	Yes	No	Don't Know	Doesn't Apply
16. I am able to get around easily in my home.	Yes	No	Don't Know	Doesn't Apply
17. Please share with us anything else you want to tell us about the services you get: Do not enter your name, Medicaid number, phone number or address.

Question	Yes	No	Don't Know	Doesn't Apply
1. I have the support I need to look for a job.	Yes	No	Don't Know	Doesn't Apply
2. I have the type of job I want.	Yes	No	Don't Know	Doesn't Apply
3. My provider showed me different kinds of jobs.	Yes	No	Don't Know	Doesn't Apply
4. My provider asked me what kind of job I wanted.	Yes	No	Don't Know	Doesn't Apply
5. When I am at work, I work in the same kind of place that others in my town work.	Yes	No	Don't Know	Doesn't Apply
6. I work in a workshop (another name for a workshop is a Community Rehabilitation Facility (CRP)/Adult Development Vocational Program (ADVP)).	Yes	No	Don't Know	Doesn't Apply
7. I make at least $7.25 an hour for each hour I work.	Yes	No	Don't Know	Doesn't Apply
8. I am treated the way that I want to be.	Yes	No	Don't Know	Doesn't Apply
9. I feel safe around the staff that work with me.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
10. I take medicine that helps me control the way I act around others.	Yes	No	Don't Know	Doesn't Apply
11. I (or my guardian) talked with my doctor and gave the doctor an "okay" for me to take medicine for behavior.	Yes	No	Don't Know	Doesn't Apply
12. My medicine helps me to feel better.	Yes	No	Don't Know	Doesn't Apply

Question	Yes	No	Don't Know	Doesn't Apply
13. I choose my own services.	Yes	No	Don't Know	Doesn't Apply
14. I get to pick the provider I want for my services/supports.	Yes	No	Don't Know	Doesn't Apply
15. I pick the staff that helps me do things.	Yes	No	Don't Know	Doesn't Apply
16. I can get help, if I need it, to make decisions about my rights.	Yes	No	Don't Know	Doesn't Apply
17. I have say-so and control over my life.	Yes	No	Don't Know	Doesn't Apply
18. I like my job.	Yes	No	Don't Know	Doesn't Apply
19. Please share with us anything else you want to tell us about the services you get: Do not enter your name, Medicaid number, phone number or address.