Your Name:  Individual's Name:  Your Phone:   Example: xxx-xxx-xxxx Relationship to Individual:   Interview Date:   Did the assessor arrive on time? Yes No Length of the assessment: Under 1 hour 1 to 2 hours 2 to 3 hours More than 3 hours Please Rate the following: 1 - Disagree 2 - Somewhat Disagree 3 - Neutral 4 - Somewhat Agree 5 - Agree The interview was scheduled at a convenient time/date. The scheduler was courteous and communicated clearly. The individual's support team was well represented at the assessment. The assessor was courteous and communicated clearly. The assessor treated me/us with dignity and respect. The assessor conveyed interest and took the time to learn about the individual's support needs. The assessment effectively captured the individual's support needs. We welcome an additional feedback regarding: 1. The Assessment tool and its Uses (Feedback to the State): 2. Scheduling: 3. The Assessor: