ab 11b 190612 assistive technology survey 6 3 12-individual easy read

Assistive Technology Survey6.3.12-Individual easy read

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Bracknell Forest Council and NHS Berkshire Joint Assistive Technology

Survey for Individuals 2012 in Easy Read


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What is happening?

The Council and NHS Berkshire are putting together a Assistive Technology Plan.

This plan aims to ensure that Assistive Technology can support and help people to live the life they want.

We would like to hear from you about your experiences. Please fill in the survey and send to: Amina Begum at Bracknell Forest Council Adult Social care & Health 4th Floor, Time Square, Bracknell, RG12 1JD or email the form to: [email protected] or call her on 01344 351204 for more detail. This survey is also available on our webpage: www.bracknell-forest.gov.uk/assistivetechnologysurvey

If you need help or support in completing this form contact our Customer Services section on 01344 352000 and they will be able to help you to fill the form either in person or over the telephone. The consultation exercise will take place from 16th March through to 7th June 2012, which will include questionnaires and workshops.


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What is Assistive Technology? Assistive technology can be lots of different things

• It can be a piece of equipment that is there to help you do something you find hard.

• It could be a bath board to help you get in and out of the bath.

• It could be a wheelchair to help you get around.

• It could be an alarm to tell you if there is a fire.

• Or it could be an alarm that you press if you need help


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Q1.Do you currently use Assistive Technology?

Q2.Please tell us what Assistive Technology you use or have used?

Please tick everything you have ��

Smoke detector

Carbon monoxide detector

Falls detector

Please tick ��

Yes Please answer Q2

No Please answer questions on the red pages


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Property exit sensor

Bed sensor

Chair sensor

Medication dispenser

Flood detector

Bogus caller button


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Temperature extreme sensor

Vibrating pillow alert

Flashing doorbell

Video door entry system

Natural gas detector

Pagers


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Environmental control unit

Lifeline

Care call pendant

Movement sensor PIR

Other


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Q3. How did you find out about Assistive Technology in Bracknell Forest?

Please tick ��

someone from GP surgery

someone from health or social services

your paid carer

family member

neighbour or friend

voluntary or community organisation

housing provider / scheme manager

Shop mobility


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Please tick ��

websites

Publicity/leaflet

Other

Q4.Were you given choices about the Assistive Technology equipment you could have?

Please tick

��

Yes

No


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Q5. How were you involved in making the choice about the Assistive Technology you have?

Please tick ��

Did someone come to talk to you

Was it done through the assessment?

No one told me

Other


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Q 6. Did they tell you about the good things about Assistive Technology?

Please tick ��

Yes

No

Please give example


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Q7. Did they tell you about the bad things about Assistive Technology?

Please give example

Please tick ��

Yes

No


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Q8. Were you happy with the time it took for the Assistive Technology equipment to arrive?

Please tick ��

Yes

No

Please give us more information


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Q9. What are the good things about having Assistive Technology?

Please tick ��

control in my life

live where I want

privacy when I need it

understand and manage risks to myself and others

get out and about

feel safe in my home

get help and support when I need it


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Please tick ��

Helps me to carry on with work /retain my work

Keeps me out of hospital

Other

Q10. What are the bad things about having Assistive Technology? Please tick ��

Batteries need to be replaced

The alarms going off at the wrong time

Phone line out of order


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Please tick ��

Other

There are no bad things


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Red pages

Q11. Do you think Assistive Technology could support and help you to live the life you want? For examples of Assistive Technology see pages 14 & 15.

Please tick ��

Yes

No

more information to make a decision

I would like to talk to someone about this


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Red pages

Q12. How do you think Assistive Technology could help you? Please tick ��

control in my life

live where I want

privacy when I need it

understand and manage risks to myself and others

get out and about

feel safe in my home

get help and support when I need it

Other


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Q13. Is there any thing else you want to tell us

Equalities Monitoring

We know that different people have different needs and different experiences of using services. We need to know what they are to be able to help make a difference.

You do not have to complete this questionnaire, but it would be very helpful to us if you do. The information you give will be kept confidence and kept in compliance with the Data Protection Act 1998.

Sex - Please tick “�” � Male � Female How would you describe your religion / belief? Please tick “�” � None � Christian (all Christian denominations) � Buddhist � Hindu � Muslim � Sikh � Jewish � Other (please specify) ________________ Which age group are you? - Please tick “�” � 18-24 � 25-34 � 35-44 � 45-54 � 55-64 � 65-74 � 75-84 � 85+


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How would you describe your sexual orientation? � Heterosexual/ straight � Gay man � Lesbian/ gay woman � Bisexual � Prefer not to say

As changes are made to health and social care services, we would like to hear your views. Would like to take part in future consultation exercises? (Please tick “�”)

� Yes �No

How would you prefer we should contact you? � By post � By email � By telephone � In person � I need large print or easy read

Please provide us with your contact details Name ___________________________ Address __________________________

__________________________ __________________________

Email __________________________ Telephone number: _________________

Thank you for taking the time to complete this survey the

information you provide will help us to improve our Assistive Technology Service

ab 11b 190612 assistive technology survey 6 3 12-individual easy read

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