DEVELOPMENTAL DISABILITIES PROGRAM
INDEPENDENT EVALUATION
PROTECTION AND ADVOCACY (P&A) SYSTEM
SELF-ADMINISTERED FORM
INSTRUCTIONS:
In addition to questions that can be answered through personal interview, there is some information that is best collected with a form like this. For the most part, the information requested requires consolidation of information you are already collecting.
The form is divided into separate sections, one section for each of the key functions1 all P&As implement. We would appreciate it if you would provide us with information that responds to the questions for each key function. When documentation is required, please append to this form.
So that data from all P&As can be rolled up to the national level, it is important that all programs that complete this questionnaire use the same time period [REPORTING PERIOD]. Therefore, please answer all questions using the following REPORTING PERIOD:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
We are providing you with a CD that contains this form, as well as a paper copy of the form. Please feel free to complete this form by computer or with a pen. If you complete this form by computer, please save it as a Word file and send it to _________________ as an attachment. Documentation should be sent to _________ in the self-addressed envelope we have provided.
If you complete this form with a pen or pencil, please return the form with all documentation to _________________ in the self-addressed envelope we have provided.
If you have any questions, please do not hesitate to call ____________ at ____________.
ID Number
[Completed by _________]
Name of Program _________________________________________________________
Executive Director ________________________________________________________
Name and contact information of person (people) completing form:
Name |
Section Completed |
Telephone Number |
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Planning and Priority Setting |
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Intake and Assistance |
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Individual Advocacy |
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Governance and Management |
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Planning and Priority Setting
All questions in this section refer to the following reporting period:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
1. What are the priorities contained in the Statement of Goals and Priorities (SGP)? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. What systemic advocacy issues are contained in the SGP? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. What populations and communities are identified in the SGP as priorities (e.g., ethnic or racial minorities, specific types of developmental disabilities, specific rural communities that are hard to serve)? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
How may clients comprised the P&A caseload during the reporting period?
No. of individual advocacy clients
How many clients in the P&A caseload were contained in each of the following categories during the reporting period? PLEASE LIST.
Quality assurance, including abuse, neglect, discrimination of rights
Education and early intervention
Child care
Health care
Employment
Housing
Transportation
Recreation
Other __________________________________________
6. What systemic advocacy issues were addressed during the reporting period? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
7. During the reporting period, what populations and communities were focused on for outreach activities (e.g., ethnic or racial minorities, specific types of developmental disabilities, specific rural communities that are hard to serve)? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
8. During the reporting period, what populations and communities were focused on for community education activities (e.g., ethnic or racial minorities, specific types of developmental disabilities, specific rural communities that are hard to serve)? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ID Number
[Completed by _________]
Intake and Assistance
All questions in this section refer to the following reporting period:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
During the reporting period how many intake forms were completed?
During the reporting period, how many intake forms were completed correctly?2
PLEASE DOCUMENT.3
Don’t know [CHECK, IF APPLICABLE.]
11. During the reporting period, how many individual advocacy cases were opened?
12. During the reporting period, how many intake forms were fully completed among individual advocacy cases opened?4
PLEASE DOCUMENT.3
Don’t know [CHECK, IF APPLICABLE.]
During the reporting period, how many initial calls did the P&A receive?
During the reporting period, how many initial calls were responded to within the maximum response time required?5
PLEASE DOCUMENT.6
Don’t know [CHECK, IF APPLICABLE.]
No requirement for maximum response time [CHECK, IF APPLICABLE.]
ID Number
[Completed by _________]
Individual Advocacy
All questions in this section refer to the following reporting period:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
How many individual advocacy cases were opened during the reporting period?
(See Question 11.)
16. How many individual advocacy cases opened during the reporting period address the priorities in your SGP?
17. How many individual advocacy cases opened during the reporting period address issues considered to be priorities for specific populations or communities in the SGP?
18. How many individual advocacy cases opened during the reporting period address emerging or emergency issues7 not anticipated in the SGP?
How many individual advocacy cases in the P&A caseload during the reporting period were (are being) litigated?
20. How many other types of individual advocacy cases opened during the reporting period consisted of:
a. Technical assistance in self-advocacy
b. Short-term assistance
c. Investigation/monitoring
d. Negotiation
e. Mediation/alternative dispute resolution
f. Administrative hearings
21. How many individual advocacy cases were closed during the reporting period?
Among individual advocacy cases closed during the reporting period, how many different client objectives were addressed?
Among those individual advocacy cases closed during the reporting period, how many separate client objectives were met?8
24. How many times during the reporting period was staff penalized for failing to maintain confidentiality in the past year?
If you used a survey during the reporting period to measure client satisfaction, how many forms were sent out (distributed)?
Did not use a survey to measure satisfaction during the reporting period
[CHECK, IF APPLICABLE.]
26. How many forms were returned?
PLEASE DOCUMENT.9
27. Overall, how satisfied do you think P&A clients were with the assistance they received during the reporting period?
Highly satisfied
Satisfied
Somewhat satisfied
Not at all satisfied
PROVIDE DOCUMENTATION.8
Don’t know [CHECK, IF APPLICABLE.]
28. How satisfied do you think P&A clients were with the efficiency of the process for meeting their requests (e.g., the P&A responded quickly) during the reporting period?
Highly satisfied
Satisfied
Somewhat satisfied
Not at all satisfied
PROVIDE DOCUMENTATION.
Don’t know [CHECK, IF APPLICABLE.]
ID Number
[Completed by _________]
Systemic Advocacy
No questions
Community Outreach and Education
No questions
Governance and Management
All questions in this section refer to the following reporting period:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
29. How many members comprise the P&A Board/Commission?
30. How many Board/Commission members are there with:
a. a developmental disability
b. a cognitive disability
c. expertise in policy and laws related to people with disability
d. expertise in business or finance
e. expertise on the developmental disabilities population
f. expertise on advocacy
g. expertise on State systems
31. How many grievances were made during the reporting period?
32. During the reporting period, how many grievances were made by individuals who did not have their cases considered by the P&A?
During the reporting period, how many grievances were made by P&A clients?
Please append all documentation and additional pages to this form and return it in the stamped, self-addressed envelope provided by _____________________.
Thank you for your assistance in completing this form.
1 Key functions are groups of activities carried out by the DD Network programs. Taken together, they cover all key aspects of program activity.
2 Correctly completed intake forms are those that comply with intake procedures regarding accuracy and appropriate amount of information to collect for callers or others who approach the P&A (e.g., in person, through written correspondence, through email) for help.
3 Documentation is tangible evidence – such as a report to the Board/Commission, summary of survey results; audit or performance review results.
4 Fully completed intake forms are those that comply with intake procedures regarding appropriate amount of information to collect on people for whom a file was opened.
5 Response time is the length of time (in working days) in which the P&A responds to someone contacting the program. Maximum response time is the length of time (in working days) in which the P&A is expected to respond to someone contacting the program.
6 Documentation is tangible evidence – such as a report to the Board/Commission, summary of survey results; audit or performance review results
7 An emerging issue is one that draws the attention of the P&A and continues to unfold as a possible issue to address immediately, in the near future, or within the next planning and priority setting process. An emergency issue is one that demands immediate action (e.g., an abuse and neglect situation, an impending legislative or policy action that would result in a loss of benefits or rights, or a private provider action that would jeopardize the health and welfare of an individual(s) with a developmental disability).
8 We assume that each client will have at least one objective and some may have more than one. Therefore, the number of separate client objectives will likely be more than the total number of clients for whom a case was closed during the reporting period.
9 Documentation is tangible evidence – such as a report to the Board/Commission, summary of survey results; audit or performance review results.
S2E-
| File Type | application/msword |
| File Title | SELF-ADMINISTERED FORM |
| Author | jjohnson1 |
| Last Modified By | jjohnson1 |
| File Modified | 2009-06-25 |
| File Created | 2009-06-25 |