New Hampshire Statewide Independent Living Council (SILC) INDEPENDENT LIVING NEEDS ASSESSMENT SURVEY 2013INDEPENDENT LIVING NEEDS ASSESSMENT SURVEY 2013

1. Are you a -please check all that apply:

Are you a -please check all that apply: Person living with a disability

Family member/caregiver/friend/other

Professional/provider

2. Type of disability- please check all that apply:

Type of disability- please check all that apply: Cognitive

Mental/Emotional

Physical

Hearing

Vision

Multiple

Other

3. Gender:

Gender: Male

Female

4. Please check where you live:

Please check where you live: Capital area

Lakes region

Monadnock/Keene area

North Country

Seacoast

Southern New Hampshire

5. Age:

Age: Under 5 years old

5 – 19

20 – 24

25 – 59

60 and Older

6. Race and Ethnicity – please check all that apply:

Race and Ethnicity – please check all that apply: American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Hispanic/Latino

White

7. Please rank the following with (1 being the most important and 7 being the least) important to you or the people you support.

Assistive Technology: adaptive equipment, computers, screen readers, etc.

Benefits/Financial Assistance: Medicare, Medicaid, Social Security, APTD, etc.

Communication Access

Employment

Health Care

Housing

Transportation

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8. Please explain your reason for choosing number 1 and include additional comments.

Please explain your reason for choosing number 1 and include additional comments.