New Hampshire Statewide Independent Living Council (SILC)

 INDEPENDENT LIVING NEEDS ASSESSMENT SURVEY 2013

 
Please help the SILC learn about the issues people living with disabilities face by answering the following questions. Thank you.
1. Are you a -please check all that apply:
2. Type of disability- please check all that apply:
3. Gender:
4. Please check where you live:
5. Age:
6. Race and Ethnicity – please check all that apply:
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.
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