Family Deaf & Hard of Hearing Survey

Your Feedback is Important

The Department of Developmental Services recently identified a substantial need for additional support for the Deaf+ community and have allocated funding to develop culturally and linguistically sensitive client supports. As the FDLRC Deaf Access Specialist, I am working to identify the needs of the our community as well as develop new resources. I want to gather some information so that we can best serve the Deaf+ community.

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* 1. What is your full name?

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* 2. What is your email or phone number?

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* 3. I am a:

Adult Served

Parent

Other Family Member Living in the Home

Other Caregiver

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* 4. What age is the client of the Regional Center

Under 3

3 - 12

13 - 18

19 - 34

35 - 64

65 +

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* 5. What geographic area do you live in?

Foothill/Glendale/Burbank

Los Angeles

Pasadena

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* 6. Are you Deaf or Hard of Hearing?

Yes, Deaf

Yes, Hard of Hearing

No, I am Hearing

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* 7. Do you have a Deaf or Hard of Hearing family member?

Yes, Deaf

Yes, Hard of Hearing