Survey

You do not have to answer all the questions on this survey.  We ask that you at least fill in the questions marked in Yellow.  Your assistance in filling out this survey will help bring attention to the needs of West Virginia's aged and disabled population, and hopefully help bring about needed change.  Any personal information is strictly for our internal use and any contact would only be performed by us to verify information.

Information you provide us will only be revealed with your permission and will be double verified by verbal confirmation and signed written permission.

Please provide the following contact information:

First Name
Last Name
Street Address
City
County
State/Province
Zip/Postal Code
Work Phone (if applicable)
Home Phone
FAX
E-mail
URL

If you have a website that is related to this site and would like it to be listed under our related links on the previous page put your address in the above URL field.

Please answer any of the following questions that you can or that are applicable to your situation.  Note: clicking the yes option will send a yes, the default "no" will be sent if you don't.

Are you 65 or older?

Yes

Personal comments, including problems, praise, or complaints about service providers or agencies (Home Maker, Case Management, Senior Centers, WV DHHR, etc...):


Do you receive services through a government program i.e. A/D Waiver, MRDD Waiver, etc.?

Yes

What program(s) are you on?


What service(s) do you receive i.e. Home Maker, Adult Companion, Chore, etc.?


Why are you on the program(s)?


How long have you been on the program(s)?


Do you feel you need more services?

Yes

If yes, what kind?


If you are on a program receiving services, do you work?

Yes

Do you work from home?

Yes

Would you work if you could maintain your current health coverage?

Yes

What services and support do you need in order to go to work?


Do you or anyone you know receive Ventilator Services?

Yes

Do you think there would be a benefit having Ventilator Services added to any of the Medicaid Programs?

Yes

Do you have strong informal support i.e. family, neighbors, church, etc.?

Yes

Were you previously in a nursing home?

Yes

Do you know about being on the A/D Waiver Program and the effect it has on the federally mandated Estate Recovery Program?

Yes

Do you self manage your case?:

Yes

While on the Medicaid program have you ever been billed by a provider (doctor, dentist, etc...) for not showing up for an appointment?:

Yes

If yes, how much were you charged?


Did you pay them?:

Yes

How do you rate WV DHHR?


How do you rate your Case Management Agency? (if applicable)


How do you rate your Home Maker Agency? (if applicable)


How do you rate your Senior Center Agency? (if applicable)


How do you rate your Adult Day Care Program? (if applicable)


How do you rate your Chore Provider? (if applicable)


Do you know who your state Delegate or Senator is?

Yes

Are you a care giver i.e. family member, neighbor, Home Maker Agency employee, Chore Provider, etc.?

Yes

If yes, what kind?


Do you feel you need help with providing care?

Yes

If yes, what kind?


How long have you been providing care?


How much time each week do you provide care?


Can you think of any additional questions we should ask on this survey?


How do you rate our web site?


KnoWare Land
Copyright © 2002 [KnoWare Land]. All rights reserved.
Revised: November 22, 2003