Dear Consumer:   
 
NYSILC is a statewide organization that develops a plan for centers for independent living to serve people with disabilities in New York State. We invite you to participate in this year’s consumer needs survey. Your answers will help us make sure that your needs are included in the statewide plan for services. Those services are delivered by the local centers for independent living to people with all types of disabilities. Our goal is to make sure that all people with disabilities can fully be part of their communities and receive services they need. Your opinions matter! 
    
At the end of the survey, you may enter to win one of five $50 gift cards from Amazon. Please complete the survey by June 25th, 2022 to be entered into the drawing.  The results of this survey will be posted on the NYSILC website in the fall www.nysilc.org.
                             
Thank you for your time!

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* 2. What is your zip code?

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* 3. Of the current services you receive, which are the most important for you to be able to live in the community? (Check up to 5 of the most important)

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* 4. Where do you get the above services? Check all the places where you regularly get services.

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* 5. How well do the services that you have selected meet your needs?

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* 6. Based on the services you selected above, what is the best way for you to receive these services? Select up to 3 that are most helpful:

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* 7. What is the best way for you to communicate with your providers?
Check up to 3 that are most helpful

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* 8. How much time does it take you to travel each way on a regular basis to get services? Select the longest time you must regularly travel.

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* 9. Which services are you not getting, but are important to help you be able to live in the community as you choose? Check up to 5 of the most important

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* 10. Please check up to 3 of the most important changes that would make it easier for you to get services.

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* 11. What prevents you from getting services?  Check up to 3 of the most important ones

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* 12. Have you been denied or unable to receive services due to the needs of your disability? If yes, where? Check all that apply.  If no, skip to next question.

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* 13. Are you currently receiving services at a Center for Independent Living (CIL)?  
Check all that apply.

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* 14. What is the longest time you would travel to get independent living services?  Please check only the longest time that is reasonable:

The following questions will help us know more about you as an individual. If you are helping someone complete the survey, or are doing it for a child, please answer the following questions based on the person for whom you are helping:

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* 15. How old are you?

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* 16. Please check one answer for your race/ethnic group

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* 17. Please indicate your primary language

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* 18. Please describe your disability (check only one)

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* 19. What is your gender?

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* 20. Are you homeless?

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* 21. Do you live in an urban, suburban, or rural location? Please check only one.

If you would like to be entered into $50 Amazon gift card drawing (5 winners will be drawn), please complete the information below.  This information will not be used other than to notify winners of the drawing. 

If you do not wish to enter the drawing, please press "done" at the end of this form to submit your survey.

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* 22. To enter the $50 Amazon gift card drawing (5 winners will be drawn), please provide the information below. This information will be used only for the drawing for the $50 gift cards.

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