Ability Awareness Resident Survey

The purpose of this survey is to better understand the needs within our community of people with different abilities.

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* 1. How would you rate the services that the Village of Homer Glen currently offers people with different abilities?

Excellent

Good

Fair

Needs improvement

Comments

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* 2. Please rank the following services in order of importance from 1-5 where 1 is most important to you and 5 is least important to you.

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* 3. Are there any additional services not included in question 2 that you feel are important?

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* 4. Please select categories that you believe are needs within each age group?

	Toddler	Children	Adults	Seniors
Special recreation	Special recreation Toddler	Special recreation Children	Special recreation Adults	Special recreation Seniors
Access to buildings	Access to buildings Toddler	Access to buildings Children	Access to buildings Adults	Access to buildings Seniors
Access to open space	Access to open space Toddler	Access to open space Children	Access to open space Adults	Access to open space Seniors
Basic needs (food, shelter, clothing, etc.)	Basic needs (food, shelter, clothing, etc.) Toddler	Basic needs (food, shelter, clothing, etc.) Children	Basic needs (food, shelter, clothing, etc.) Adults	Basic needs (food, shelter, clothing, etc.) Seniors
Transportation	Transportation Toddler	Transportation Children	Transportation Adults	Transportation Seniors
Equipment	Equipment Toddler	Equipment Children	Equipment Adults	Equipment Seniors

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* 5. Please list any support groups that you and/or your family or friends belong to

a)

b)

c)

d)

e)

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* 6. Would you be interested in volunteering for events hosted by the Ability Awareness Committee?

Yes

No

Maybe

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* 7. If you answered yes to question 6, what is your preferred method of contact?

Phone

Email

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* 8. Does anyone in your household have a disability?

Yes

No

Optional: List disability

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* 9. Additional Comments or Suggestions: