2021-2022 Outcome Survey - Individuals and Families Question Title * 1. Name Question Title * 2. Date Question Title * 3. Email Question Title * 4. Phone Question Title * 5. What event, activity, or grant are you filling this out for? Question Title * 6. What town do you live in? Question Title * 7. Race/Ethnicity White Alone Black or African American Alone Asian Alone American Indian or Alaska Native Alone Native Hawaiian/ Other Pacific Islander Alone Hispanic/Latino Two or more races Race Unknown Question Title * 8. Age Under 21 21-65 Over 65 Question Title * 9. Gender Female Male Other Question Title * 10. Please choose the statement that best describes you I am an individual with an intellectual or developmental disability. I am a family member of an individual with an intellectual or developmental disability. Other Question Title * 11. Are you willing to be contacted to share your story with us? If yes, how can we contact you? Question Title * 12. How has/will this program help you? (Check all that apply.) Identify my disability Give me confidence and pride Know my rights and responsibilities Learn how to access information Set goals Make my own decisions Problem solving skills Listening and learning Talk about my disability Request accommodations Ask for help to complete a task Other Question Title * 13. Check all the ways this program has will help you to better advocate for yourself and others. I will tell people about my goals. I will tell people about what kinds of supports I need. I will tell people about what kind of services I need. I will make more of my own choices about my life. I will tell people what is important to me. I will talk about myself more. Question Title * 14. What kind of advocacy activities has/will this program help you do better? Individual Education Plan meetings VRD Individual Plan for Employment DDSN Individual Service Plan Medicaid Case Management Plan Peer-peer learning and/or leadership Medical services Legal services Providing input on legislation or legal regulations Serving on a board, coalition, committee, etc. Advocacy Day Spoke up on behalf of someone else Other Question Title * 15. Do you participate in any of the following? Check all that apply. Cross-disability coalition Governing Body Policy/Advisory Board Leadership position Question Title * 16. Are you satisfied with the event/grant? Yes Somewhat No Done