Advocacy Priorities Survey FY 2012
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1. Advocacy Priorities Survey

What do you think are the most important issues for people with disabilities in Wisconsin.

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1. What County do you currently reside?

What County do you currently reside?

2. Please choose your top two priority issues. Number one is your higher priority. You will only be able to choose two priorities in this question. (We understand that all of the issues represented here are priorities, but need to make sure we have enough resources to make an impact in areas that are most important to the people of Wisconsin.)

	Number 1 - Top Priority	Number 2 Priority
Adaptive Equipment/Home Modification	*Please choose your top two priority issues. Number one is your higher priority. You will only be able to choose two priorities in this question. (We understand that all of the issues represented here are priorities, but need to make sure we have enough resources to make an impact in areas that are most important to the people of Wisconsin.) Adaptive Equipment/Home Modification Number 1 - Top Priority	Adaptive Equipment/Home Modification Number 2 Priority
Access to Personal Care/Personal Assistance Services	Access to Personal Care/Personal Assistance Services Number 1 - Top Priority	Access to Personal Care/Personal Assistance Services Number 2 Priority
Disability Rights Laws Compliance and Enforcement	Disability Rights Laws Compliance and Enforcement Number 1 - Top Priority	Disability Rights Laws Compliance and Enforcement Number 2 Priority
Mental Health and Substance Abuse Services	Mental Health and Substance Abuse Services Number 1 - Top Priority	Mental Health and Substance Abuse Services Number 2 Priority
Benefits Counseling	Benefits Counseling Number 1 - Top Priority	Benefits Counseling Number 2 Priority
Transportation	Transportation Number 1 - Top Priority	Transportation Number 2 Priority
Employment	Employment Number 1 - Top Priority	Employment Number 2 Priority
Quality Education	Quality Education Number 1 - Top Priority	Quality Education Number 2 Priority
Accessible and Affordable Housing	Accessible and Affordable Housing Number 1 - Top Priority	Accessible and Affordable Housing Number 2 Priority
Access to Affordable Health Care	Access to Affordable Health Care Number 1 - Top Priority	Access to Affordable Health Care Number 2 Priority
Accessible Social and Recreational Activities	Accessible Social and Recreational Activities Number 1 - Top Priority	Accessible Social and Recreational Activities Number 2 Priority

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3. Would you be willing to work with others on any of these topics?

Would you be willing to work with others on any of these topics?

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4. Would you like to receive information on any of these topics?

Would you like to receive information on any of these topics?

5. If you answered yes to either question #3 or #4, please provide your contact information.

If you answered yes to either question #3 or #4, please provide your contact information. Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:

6. Would you like to share your story. (Optional)

Would you like to share your story. (Optional)

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