Do you know what to do in the following situations?

I know what to do

I would like to learn more

Explain / Comment

1. Keeping your personal items safe from being stolen (e.g, money, clothing, electronics, etc.)?

Yes
No
Sometimes
Not Sure

Yes
No

2. Keeping your personal information private (e.g., bank accounts, computer use, medical information, your private business, etc.)?

Yes
No
Sometimes
Not Sure

Yes
No

3. Someone borrows money and doesn’t pay you back (or borrows something and doesn’t return it)?

Yes
No
Sometimes
Not Sure

Yes
No

4. Your attendant hasn’t shown up (e.g., contacting someone)?

Yes
No
Sometimes
Not Sure

Yes
No

5. The fire alarm is activated? (e.g., trusting that the staff knows what to do)?

Yes
No
Sometimes
Not Sure

Yes
No

6. Answering the door (e.g., knowing who is at the door, giving permission to enter, locking and opening your door, etc.)?

Yes
No
Sometimes
Not Sure

Yes
No

7. Someone threatens you?

Yes
No
Sometimes
Not Sure

Yes
No

8. Someone physically hurts you?

Yes
No
Sometimes
Not Sure

Yes
No

9. Someone is controlling you (e.g., not allowing you to make your own decisions, pressuring you to do things you don’t want to do, etc.)?

Yes
No
Sometimes
Not Sure

Yes
No

10. Someone forces you to do sexual things against your will?

Yes
No
Sometimes
Not Sure

Yes
No

11. Someone punishes you (e.g., puts on your brakes, withholds food, takes away your communication display and/or VOCA, etc.)?

Yes
No
Sometimes
Not Sure

Yes
No

12. Someone who provides services does not know how to handle you (e.g., lift, feed, dress, etc.) and you are afraid for your safety?

Yes
No
Sometimes
Not Sure

Yes
No

13. You are not satisfied with the safety practices of people who work with you (e.g., their personal hygiene, knowledge of safety procedures, etc.)?

Yes
No
Sometimes
Not Sure

Yes
No

14. Someone makes you feel afraid or uneasy?

Yes
No
Sometimes
Not Sure

Yes
No

15. Other: Please specify.

Yes
No
Sometimes
Not Sure

Yes
No