Georgia Transition Resource Mapping Questionnaire

We would like to identify as many programs as possible that support individuals with disabilities and their families in Georgia. In doing this, we are interested in what programs are doing, where they are providing services, and whom they are serving. We understand that some organizations may provide just one or two programs that reach individuals with disabilities and their families, and others may have a dozen or more. It would be helpful for our mapping efforts if one survey was completed per program. The results from this questionnaire will assist our efforts to construct both a physical "map" of resources in Georgia, as well as a "map" of activities across areas of Transition Plans.

Please complete one questionnaire per program, project, or service.

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* 1. Name of person completing this form:

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* 2. Name of organization:

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* 3. Name of program:

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* 4. Best person to contact for more information:

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* 5. Telephone number:

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* 6. E-mail:

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* 7. Website

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* 8. Location(s) of program:

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* 9. Does this program have a primary focus on a particular disability type?

Yes

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* 10. If you answered yes to Q9, what population do you work primarily with?

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* 11. What geographic region does this program serve? (please select 1 of the 3 choices below)

Mostly a single county (please specify):

In several counties (please specify):

In many different parts of the state (please specify):

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* 12. About how many people does the program serve annually in the following groups?

Children under age 5

School-age child (5-18)

Transition-age (19 and older)

Families

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* 13. How is the program funded?

Fees for service

Third-party insurance

Medicaid

Local school district

State agency

Federal agency

Donations

Grants

Other (please specify)

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* 14. In which area (s) of Transition to Adulthood does the program activity fit? (Check all that apply)

Self-Determination

Assistive Technology

Postsecondary Education Opportunities

Employment

Residential Services

Recreation and Leisure

Healthcare

Legal Resources

Assessments

Family Resources

Waivers and SSI

Other (please specify)

Georgia Transition Resource Mapping Questionnaire

Question Title

* 1. Name of person completing this form:

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* 2. Name of organization:

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* 3. Name of program:

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* 4. Best person to contact for more information:

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* 5. Telephone number:

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* 6. E-mail:

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* 7. Website

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* 8. Location(s) of program:

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* 9. Does this program have a primary focus on a particular disability type?

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* 10. If you answered yes to Q9, what population do you work primarily with?

Question Title

* 11. What geographic region does this program serve? (please select 1 of the 3 choices below)

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* 12. About how many people does the program serve annually in the following groups?

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* 13. How is the program funded?

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* 14. In which area (s) of Transition to Adulthood does the program activity fit? (Check all that apply)

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* 15. Please provide a brief description of the program.

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* 16. What tools do you use to measure outcomes for this project?

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* 17. What key outcomes do you measure?

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* 18. Are you willing to share data or measurement tools?