"Rsa-R Family Member/Significant Other Version Survey Template"

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Code______
RSA-R
Family Member/Significant Other Version
Please circle the number below which reflects how accurately the following statements describe the activities,
values, policies, and practices of this program.
1
2
3
4
5
Strongly Disagree
Strongly Agree
N/A= Not Applicable
D/K= Don’t Know
1. Staff make efforts to welcome my loved one and help him/her to feel
1
2
3
4
5
N/A
D/K
comfortable in this program.
2. The physical space of this program (e.g., the lobby, waiting rooms, etc.)
1
2
3
4
5
N/A
D/K
feels inviting and dignified.
3. Staff encourage my loved one to have hope and high expectations for his/her
1
2
3
4
5
N/A
D/K
recovery.
4. My loved one can change his/her clinician or case manager if he/she wants
1
2
3
4
5
N/A
D/K
to.
5. My loved one can easily access his/her treatment records if he/she wishes.
1
2
3
4
5
N/A
D/K
6. Staff do not use threats, bribes, or other forms of pressure to influence the
1
2
3
4
5
N/A
D/K
behavior of my loved one.
7. Staff believe that my loved one can recover.
1
2
3
4
5
N/A
D/K
8. Staff believe that my loved one has the ability to manage his/her own
1
2
3
4
5
N/A
D/K
symptoms.
9. Staff believe that program participants can make their own life choices
regarding things such as where to live, when to work, whom to be friends with,
1
2
3
4
5
N/A
D/K
etc.
10. Staff listen to my loved one and respect his/her decisions about his/her
1
2
3
4
5
N/A
D/K
treatment and care.
11. Staff regularly ask my loved one about his/her interests and the things
1
2
3
4
5
N/A
D/K
he/she would like to do in the community.
12. Staff encourage my loved one to take risks and try new things.
1
2
3
4
5
N/A
D/K
13. This program offers specific services that fit the unique culture and life
1
2
3
4
5
N/A
D/K
experiences of my loved one.
14. My loved one is given opportunities to discuss his or her spiritual needs and
1
2
3
4
5
N/A
D/K
interests when he or she wishes.
15. My loved one is given opportunities to discuss his or her sexual needs and
1
2
3
4
5
N/A
D/K
interests when he or she wishes.
16. Staff help my loved one to develop and plan for life goals beyond
managing symptoms or staying stable (e.g., employment, education, physical
1
2
3
4
5
N/A
D/K
fitness, connecting with family and friends, hobbies).
17. Staff assist my loved one with getting jobs.
1
2
3
4
5
N/A
D/K
18. Staff help my loved one to get involved in non-mental health related
1
2
3
4
5
N/A
D/K
activities, such as church groups, adult education, sports, or hobbies.
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
Code______
RSA-R
Family Member/Significant Other Version
Please circle the number below which reflects how accurately the following statements describe the activities,
values, policies, and practices of this program.
1
2
3
4
5
Strongly Disagree
Strongly Agree
N/A= Not Applicable
D/K= Don’t Know
1. Staff make efforts to welcome my loved one and help him/her to feel
1
2
3
4
5
N/A
D/K
comfortable in this program.
2. The physical space of this program (e.g., the lobby, waiting rooms, etc.)
1
2
3
4
5
N/A
D/K
feels inviting and dignified.
3. Staff encourage my loved one to have hope and high expectations for his/her
1
2
3
4
5
N/A
D/K
recovery.
4. My loved one can change his/her clinician or case manager if he/she wants
1
2
3
4
5
N/A
D/K
to.
5. My loved one can easily access his/her treatment records if he/she wishes.
1
2
3
4
5
N/A
D/K
6. Staff do not use threats, bribes, or other forms of pressure to influence the
1
2
3
4
5
N/A
D/K
behavior of my loved one.
7. Staff believe that my loved one can recover.
1
2
3
4
5
N/A
D/K
8. Staff believe that my loved one has the ability to manage his/her own
1
2
3
4
5
N/A
D/K
symptoms.
9. Staff believe that program participants can make their own life choices
regarding things such as where to live, when to work, whom to be friends with,
1
2
3
4
5
N/A
D/K
etc.
10. Staff listen to my loved one and respect his/her decisions about his/her
1
2
3
4
5
N/A
D/K
treatment and care.
11. Staff regularly ask my loved one about his/her interests and the things
1
2
3
4
5
N/A
D/K
he/she would like to do in the community.
12. Staff encourage my loved one to take risks and try new things.
1
2
3
4
5
N/A
D/K
13. This program offers specific services that fit the unique culture and life
1
2
3
4
5
N/A
D/K
experiences of my loved one.
14. My loved one is given opportunities to discuss his or her spiritual needs and
1
2
3
4
5
N/A
D/K
interests when he or she wishes.
15. My loved one is given opportunities to discuss his or her sexual needs and
1
2
3
4
5
N/A
D/K
interests when he or she wishes.
16. Staff help my loved one to develop and plan for life goals beyond
managing symptoms or staying stable (e.g., employment, education, physical
1
2
3
4
5
N/A
D/K
fitness, connecting with family and friends, hobbies).
17. Staff assist my loved one with getting jobs.
1
2
3
4
5
N/A
D/K
18. Staff help my loved one to get involved in non-mental health related
1
2
3
4
5
N/A
D/K
activities, such as church groups, adult education, sports, or hobbies.
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
Code______
19. Staff help my loved one to include people who are important to him/her in
his/her recovery/treatment planning (such as family, friends, clergy, or an
1
2
3
4
5
N/A
D/K
employer).
20. Staff introduce my loved one to others in recovery who can serve as role
1
2
3
4
5
N/A
D/K
models or mentors.
21. Staff connect my loved one with self-help, peer support, or consumer
1
2
3
4
5
N/A
D/K
advocacy groups and programs.
22. Staff help my loved one to find ways to give back to the community (i.e.,
1
2
3
4
5
N/A
D/K
volunteering, community services, neighborhood watch/cleanup).
23. My loved one is encouraged to help staff with the development of new
1
2
3
4
5
N/A
D/K
groups, programs, or services.
24.Program participants are encouraged to be involved in the evaluation of this
1
2
3
4
5
N/A
D/K
program’s services and service providers.
25. My loved one is encouraged to attend agency advisory boards and
1
2
3
4
5
N/A
D/K
management meetings
26. Staff talk with my loved one about what it takes to complete or exit the
1
2
3
4
5
N/A
D/K
program.
27. Staff help my loved one keep track of the progress he/she makes towards
1
2
3
4
5
N/A
D/K
his/her personal goals.
28. Staff work hard to help my loved one fulfill his/her personal goals.
1
2
3
4
5
N/A
D/K
29. My loved one is or can be involved in facilitating staff trainings and
1
2
3
4
5
N/A
D/K
education programs at this agency.
30. Staff listen, and respond, to my loved ones cultural experiences, interests, and
1
2
3
4
5
N/A
D/K
concerns.
31. Staff are knowledgeable about special interest groups and activities in the
1
2
3
4
5
N/A
D/K
community.
32. Agency staff are diverse in terms of culture, ethnicity, lifestyle, and
1
2
3
4
5
N/A
D/K
interests.
*For family/sig oth only
33. Staff make efforts to welcome me and make me feel comfortable in this
1
2
3
4
5
N/A
D/K
program.
34. Staff encourage me to have hope and high expectations for my loved one’s
1
2
3
4
5
N/A
D/K
recovery.
35. Staff listen to me and respect my opinion about my loved one’s treatment
1
2
3
4
5
N/A
D/K
and care.
36. Staff include me in my loved one’s recovery/ treatment planning.
1
2
3
4
5
N/A
D/K
37. I am encouraged to help staff with the development of new groups,
1
2
3
4
5
N/A
D/K
programs, or services.
38. I am encouraged to be involved in the evaluation of this program’s services
1
2
3
4
5
N/A
D/K
and service providers.
39. I am encouraged to attend agency advisory boards and management
1
2
3
4
5
N/A
D/K
meetings, if I want.
40. I am/ can be involved in facilitating staff trainings and education programs
1
2
3
4
5
N/A
D/K
at this agency.
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
Code______
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
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