IHSS Survey

We are using this survey to gather information from IHSS consumers on how they use IHSS and how the proposed IHSS cuts will affect them.

* Name:

* Address:

* Phone Number:

* E-mail:

* Age:

What is your disability/what are your disabilities?

Generally, how does your disability/disabilities limit your ability to take care of yourself in your home without assistance? (i.e., if you “can’t cook”, why not? Weak arms, danger to self, can’t see?)

* How long have you received IHSS services?

* How many hours are you authorized to receive in IHSS services per month?

* Do you know your overall Functional Index Score (“FI”)?

Yes

If yes, what is your overall functional index score?

What is your current Functional Rank for Housework (Domestic Service) (if you know it)?

What is your current Functional Rank for Laundry (Related Service) (if you know it)?

What is your current Functional Rank for Shopping and Errand (Related Service) (if you know it)?

What is your current Functional Rank for Meal Preparation and Clean-up (Related Service) (if you know it)?

Have you received any notification from the state that the number of hours or types of services you can receive are going to be reduced or that your eligibility will be cut entirely?

What would happen if you no longer had help from an IHSS provider or if your domestic and related IHHS services are cut?

* Indicates Response Required

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