Facility Based Day Providers, please complete the following questionnaire (only one per agency). Please identify just one person to acquire the information needed and act as the respondent for the agency.

Please contact khauth@orangegrove.org if you have any difficulty with this form.

Facility Based Day Questionnaire

1. Name of person completing this form

2. Email Address

3. Phone number

4. Agency

5. Total number of facility based service recipients (defined as individuals which you typically bill FB Day 75% of time or more).

6. Number (of # 5) in some type of sheltered employment

7. Number (of #5) that have transitioned from FB to CB and/or SE within the last year?

8. Number (of # in 5) in some type of developmental or non-vocationally related facility based day?

9. Number (of # in 5) that are not in your residential program still residing with their family?

10. Number (of # in 5) that are served by another provider for their residential services?

11. Number (of # in 5) that are 50 years of age or older?

12. Square footage of facilities utilized for Facility Day Programs (separate adm, clerical, case mang. and records space)?

13. Do you own or lease the program space? Own Lease $1 year or free lease Other

14. Is there currently a mortgage or real estate loan attached to this program space? Yes No

15. If yes, what is the approximate amount?

16. Have you already reduced or eliminated facility based services? Yes No

17. If yes, what reductions have you implemented?

To prove you are a human, please tell us which has four legs?

Facility Based Day Providers Questionnaire

Facility Based Day Questionnaire