Brain Injury Alliance

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1. Are you a

Are you a   person who experienced a brain injury? family member of a person who experienced a brain injury? Caregiver of a person who experienced a brain injury? Other

2. What is the current age of the person who experienced a brain injury?

What is the current age of the person who experienced a brain injury?   0 - 21 22 - 40 41 - 60 60 - 64 65 plus

3. What age did the brain injury occur?

What age did the brain injury occur?   Before the age of 21 After the age of 21

4. What is the gender of the person who experienced a brain injury?

What is the gender of the person who experienced a brain injury?   Female Male

5. Is the person who experienced a brain injury a resident of South Dakota?

Is the person who experienced a brain injury a resident of South Dakota?   Yes No

6. If yes, what county do they live in?

If yes, what county do they live in?

7. Was the person who experienced a brain injury a resident of South Dakota when the injury occurred?

Was the person who experienced a brain injury a resident of South Dakota when the injury occurred?   Yes No

8. What services has the person who experienced a brain injury received? (Check all that apply.)

What services has the person who experienced a brain injury received? (Check all that apply.)   Acute medical Inpatient rehabilitation Outpatient rehabilitation Community re-integration Day services 24 hour services Assisted Living Nursing Home

9. Currently, where is the person who experienced a brain injury receiving those services?

Currently, where is the person who experienced a brain injury receiving those services?   In-state Out-of-state

10. What services does the person who experienced a brain injury need or require that are not currently available? (Please be as specific as possible.)

What services does the person who experienced a brain injury need or require that are not currently available? (Please be as specific as possible.)

11. What are the life goals of the person who experienced a brain injury? (Check all that apply.)

What are the life goals of the person who experienced a brain injury? (Check all that apply.)   live in my own apartment or home be employed volunteer further education drive

Other (please specify)

12. What other information would you like to share with us?

What other information would you like to share with us?