JBSRA Survey Question Title * 1. How many members of your household who participate or would be eligible to participate in programs and activities of JBSRA are of each of the following ages? Under 6 years 6 - 9 years 10 - 15 years 16 - 21 years 22 - 25 years 26 - 34 years 35 - 44 years 45 - 50 years 51 - 64 years 65+ years Question Title * 2. Please check ALL the primary diagnoses for members of your household who participate or would be eligible to participate in programs and activities of JBSRA. [Check ALL that apply to members of your household.] NOTE: If no one in your household participates in programs and activities, please check the primary diagnoses for those household members who could participate in programs and activities. Attention Deficit Disorder/ADHD Autism/Asperger Syndrome Behavior/emotional disorder Cerebral Palsy Communication delays Developmental disability Down Syndrome Early Childhood Delays Fetal Alcohol Syndrome Fragile X Syndrome Hearing impaired Learning disabled Medically Fragile Mental Illness Multi-needs Obsessive Compulsive Disorder Physical disability Sensory integration Seizure disorder/epilepsy Spinal Cord Injury Stroke Traumatic Brain Injury Visually impaired Other (please specify) Question Title * 3. Have any members of your household participated in programs and activities of JBSRA? Yes No Next >>