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.