MY INDIVIDUAL EXPERIENCE SURVEY - DAY SUPPORTS

With NC DHHS Home and Community Based Settings (HCBS)

Section I: About you and your service

My Street Address
I have a guardian.
I have a power of attorney.
I am my own guardian.
I do not know if I have a guardian.

Section II: General Questions

Job

No
Money

Signature Page

If you were asked to fill out the survey, please provide the survey number you were given.

If you have feedback or questions, please email: HCBSTransPlan@dhhs.nc.gov.