JBSRA Survey

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1. How many members of your household who participate or would be eligible to participate in programs and activities of JBSRA are of each of the following ages?

How many members of your household who participate or would be eligible to participate in programs and activities of JBSRA are of each of the following ages?   Under 6 years
6 - 9 years
10 - 15 years
16 - 21 years
22 - 25 years
26 - 34 years
35 - 44 years
45 - 50 years
51 - 64 years
65+ years

2. Please check ALL the primary diagnoses for members of your household who participate or would be eligible to participate in programs and activities of JBSRA. [Check ALL that apply to members of your household.]

NOTE: If no one in your household participates in programs and activities, please check the primary diagnoses for those household members who could participate in programs and activities.

Please check ALL the primary diagnoses for members of your household who participate or would be eligible to participate in programs and activities of JBSRA. [Check ALL that apply to members of your household.] NOTE: If no one in your household participates in programs and activities, please check the primary diagnoses for those household members who could participate in programs and activities.   Attention Deficit Disorder/ADHD Autism/Asperger Syndrome Behavior/emotional disorder Cerebral Palsy Communication delays Developmental disability Down Syndrome Early Childhood Delays Fetal Alcohol Syndrome Fragile X Syndrome Hearing impaired Learning disabled Medically Fragile Mental Illness Multi-needs Obsessive Compulsive Disorder Physical disability Sensory integration Seizure disorder/epilepsy Spinal Cord Injury Stroke Traumatic Brain Injury Visually impaired

Other (please specify)

3. Have any members of your household participated in programs and activities of JBSRA?

Have any members of your household participated in programs and activities of JBSRA?   Yes No