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State Plan for Independent Living
Community Survey
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1.
Check the description that best describes you or the person you are answering for:
(Required.)
Person with a disability (with or without help)
Service Provider
Family member or friend of a person with a disability
Ally of the disability community
Other (please specify)
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2.
Check the box or boxes that best describe your disability or that of the person you are answering for:
(Required.)
Physical/Mobility
Visual Impairment
Deaf/Hard of Hearing
Intellectual/Cognitive
Mental/Emotional
Traumatic Brain Injury
Neurodivergent
Developmental
Other (please specify)
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3.
In the past year, what has been the biggest challenge related to your disability, that has limited your independence and/or participation in the community?
(Required.)
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4.
If you were able, what change would you make in Idaho to improve life for people with disabilities?
(Required.)
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5.
What changes could Centers for Independent Living or other disability programs make to better support people with disabilities with their independence?
(Required.)
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6.
Age:
(Required.)
0 - 11
12 - 20
21 - 30
31 - 40
41 - 50
51 - 60
60+
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7.
Please enter your zip code.
(Required.)
8.
Thanks for your time. Your voice matters and helps make a difference.
(Optional)
If you’d like to talk to someone at a Center for Independent Living near you, please provide the following information:
Name
Phone
Email
City
Topic you want to discuss
9.
The best way to reach me is:
Phone
Email
Text
