STAFF SELF-ASSESSMENT SURVEY
Please complete this self-assessment survey to assist us with providing quality supports and services to our clients. Provide comments for concerns you have, for No answers, or to expand on each area in the survey. Sign, date, and return the completed form to the Program Administrator.
Staff	MONTH/YEAR
Services Provided	SLC	PS-Day	PS-Qtr	LSD1	Other (specify)
Area	Question	Unsure	Yes	No
Decisions	Do you assist your client with decision-making skills?
Do you assist your client with making decisions about his health?
Do you assist your client with making decisions about his finances?
Do you assist your client with making informed decisions?

Choice	Do you assist your client with making informed choices?
Do you make an effort to provide your client with alternative choices?

Rights & Responsibilities	Do you provide training on client rights as a US citizen and as a disabled person (Bill of Rights)?
Do you provide training on client responsibilities and staff responsibilities in supported living?

HIPAA	Do you remember to consider your client's personal privacy and encourage your client to have private time?
Do you knock on your client's door and wait for an answer before entering?

Social Inclusion	Do you help your client with going places and doing things he wants to do in the way he can do them?
Do you feel your client's participation and/or independence in the community is where he wants it to be?

Relationships	Do you encourage and make opportunities for your client to socialize in any way with neighbors, friends, or family?
Do you encourage your client to be connected to a natural support network (people who are not staff)?

Dignity & Respect	Do you treat your client with consideration – all of the time?
Do you listen to your client's ideas?

Security & Continuity	Do you try to provide your client with a feeling of security (at home, in the community, around new people, etc)?
Do you try to encourage your client to experience life in a smooth manner rather than with lots of ups and downs?

Resolutions	Do you assist your client with conflict (complaints, conflicts, grievances) resolution?
Are you aware that you are legally bound to report any suspicion of abuse, neglect, or exploitation?
Do you provide your client information about the meaning of abuse, neglect, and exploitation?
Are you aware of the hierarchy for reporting conflicts, complaints, and grievances?

Health & Safety	Do you help your client to make and keep appointments (medical, dental, specialists) when the client requests it?
Do you train your client to understand what to do in case of a big emergency or a small problem?

Expose, Educate, Experience	Do you encourage your client to try new things and experience life to its fullest?
Do you help your client to learn about, become familiar with, or try new things?
Have you helped your client learn new things?

Goal Choice & Progress	Do you assist your client with choosing his own goals?
Do you feel the goals you give to the WSC for the Annual Report are the same goals that are on the Support Plan?
Do you feel that your client makes adequate progress on his goals?

Change	Do you teach your client that he can change his mind, his staff, and his services, etc while at the same time teaching a sense of responsibility and consistency?
Do you know what to do if your client is no longer happy with a goal or his services and wants a change?

Person-Centered Process	Do you help your client achieve goals that are important to him and also meet his needs?
Do you help your client achieve his goals by providing opportunities to expand life experiences?
Do you "know" your client and his significant others (family, loved ones, dear friends)?

General	Do you have a copy of your client's Support Plan and Implementation Plan?
Are you aware that you are one of many staff who have come and gone in your client's life?
Are you aware that one of your main goals in your client's life is to phase out his need for your help?
Are you aware that if you disappear from your client's life tomorrow, he will find a new staff?
Do you encourage your client to become as independent in the things he can – all of the time.
Do you write objective, clear, specific casenotes?
Do you feel you receive adequate training to be able to work with your client?
Do you feel you have a variety of training techniques in order to help your client learn a skill or gain knowledge?
Do you feel you provide your client with adequate opportunities for practice?
Do your casenotes reflect the concepts on this survey that you should be teaching your client?

Which 3 areas in this survey do you have most trouble with when working with your client?

Provide one example of how you have assisted a client with learning about, becoming familiar with, or trying out new things.

What suggestions do you have that would improve your ability to provide your client with quality services?

What suggestions do you have that would help improve this company?

What training do you think you need or that you would like to have?

Signature	Date