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
Assistive Technology Survey6.3.12-Individual 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.
Assistive Technology Survey6.3.12-Individual easy read
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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
Assistive Technology Survey6.3.12-Individual easy read
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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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Please tick everything you have ����
Property exit sensor
Bed sensor
Chair sensor
Medication dispenser
Flood detector
Bogus caller button
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Please tick everything you have ����
Temperature extreme sensor
Vibrating pillow alert
Flashing doorbell
Video door entry system
Natural gas detector
Pagers
Assistive Technology Survey6.3.12-Individual easy read
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Please tick everything you have ����
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
Assistive Technology Survey6.3.12-Individual easy read
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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
Assistive Technology Survey6.3.12-Individual easy read
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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
Assistive Technology Survey6.3.12-Individual easy read
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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
Assistive Technology Survey6.3.12-Individual easy read
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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
Assistive Technology Survey6.3.12-Individual easy read
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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