Demographic Information

Every three years the Office for the Blind conducts a statewide needs assessment of individuals who are blind and visually impaired. Thank you for taking the time to participate in this survey and answer questions about your individual needs. By participating in this survey you assist us in identifying service needs and trends. As a member of the community your knowledge and experience will provide us with important information. The more responses we receive to this questionnaire, the more likely we will gain a better understanding of where the greatest service needs are in our state. If you have any questions, please call Cora McNabb at 1-800-321-6668 or by email at  

* 1. Please identify who is filling out this questionnaire?

* 2. Age of individual who is blind or visually imapired

* 3. Gender of individual who is blind or visually impaired

* 4. Race/Ethnicity of person who is blind or visually impaired

* 5. Tell us about your living arrangements. Do you live

* 6. In the box please list your county of residence

* 7. Mark one of the best that applies to you

* 8. Please mark one of the categories below that best applies to your vision impairment.

* 9. Please mark the one that applies to the cause of your vison loss

* 10. Age of start (onset) of vision loss

* 11. Is your vision likely to deteriorate or your vision loss progressive?

* 12. Are you a veteran?

* 13. What was the highest educational level that you achieved? (Check only one)

* 14. What sources of income do you rely on most to pay your daily living expenses? Check all that apply.

* 15. What category best describes your household income?