Please help the SILC learn about the issues people living with disabilities face by answering the following questions. Thank you.

* 1. Are you a -please check all that apply:

* 2. Type of disability- please check all that apply:

* 3. Gender:

* 4. Please check where you live:

* 5. Age:

* 6. Race and Ethnicity – please check all that apply:

* 7. Please rank the following with (1 being the most important and 7 being the least) important to you or the people you support.

* 8. Please explain your reason for choosing number 1 and include additional comments.

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