2021-2022 Outcome Survey - Individuals and Families

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* 1. Name

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* 2. Date

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* 3. Email

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* 4. Phone

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* 5. What event, activity, or grant are you filling this out for?

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* 6. What town do you live in?

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* 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

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* 8. Age

Under 21

21-65

Over 65

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* 9. Gender

Female

Male

Other

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* 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

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* 11. Are you willing to be contacted to share your story with us?
If yes, how can we contact you?

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* 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

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* 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.

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* 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

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* 15. Do you participate in any of the following? Check all that apply.

Cross-disability coalition

Governing Body

Policy/Advisory Board

Leadership position

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* 16. Are you satisfied with the event/grant?

Yes

Somewhat

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?

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* 7. Race/Ethnicity

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* 8. Age

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* 9. Gender

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* 10. Please choose the statement that best describes you

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* 11. Are you willing to be contacted to share your story with us? If yes, how can we contact you?

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* 12. How has/will this program help you? (Check all that apply.)

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* 13. Check all the ways this program has will help you to better advocate for yourself and others.

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* 14. What kind of advocacy activities has/will this program help you do better?

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* 15. Do you participate in any of the following? Check all that apply.

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* 16. Are you satisfied with the event/grant?

* 11. Are you willing to be contacted to share your story with us?
If yes, how can we contact you?