East Sussex Pilot SAQ; TASC Questionnaire (pdf - 512Kb)

Completing your questionnaire
Please follow these points:
It‟s up to you whether you complete your questionnaire on your own,
with your carer, or with friends and family.
Please be honest. Please complete the questionnaire as fully as
possible.
Please tick in the column „What I think‟, Your Care co-ordinator will
complete the next column, shaded in light grey and the final decision
and point‟s allocation will be completed by East Sussex County
Council. These columns are shaded in yellow.
Please tick the statement that best describes your situation. If you do
not agree with any of the statements in a question or do not find them
applicable to you please tell us why. Our contact details are on the
front page.
If you do not understand any of the questions, please do not hesitate
to ask the person who gave this questionnaire to you who will try and
answer your question.
For each question, there are points allocated to the answer. These
will be used to help us work out how much money you should be
offered in your personal budget.
Please only complete the „What I think‟ section. Your Care coordinator
will complete the next section. If their answers are different
to yours, they will discuss the reasons with you to eventually reach a
final score.
If you do not complete this questionnaire, you will not be able to receive an
Individual Budget.
An Individual Budget will not affect any benefits that you receive or affect
your or your carer‟s eligibility status.
What happens next
After you have completed your questionnaire, please return it to the person
who gave this questionnaire to you. You will then be contacted to let you
know if you are eligible for an Individual Budget and how much you will get.
East Sussex County Council
Adult Social Care Department
Page 2 of 15
Self Assessment Questionnaire
K Mackay In-Control Pilot (Health) – V2