This survey will help launch the Inclusive Healthy Verona Initiative, which aims to create an inclusive, connected, and caring community by advocating for and implementing intentional policy, system, and environmental changes that support people of all ages and abilities in their potential to thrive throughout all stages of life.

Please only submit one survey per individual.

Thank you for participating!

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* 1. Are you completing this survey on behalf of yourself, a household member, a family member not in your household, or a care recipient with a disability?

If you are completing the survey on behalf of someone else, please answer all of the following questions from their perspective, and not your own.

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* 2. Please indicate if you are an individual with any of the following disabilities:

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* 3. Which section of town do you live in?

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* 4. What is your age?

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* 5. How many days a week, on average, do you spend outside your home, work, or school moving around town?

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* 6. Please respond to the following statements about inclusivity in Verona and your activity in public spaces in Verona.

  Strongly agree Agree Neutral Disagree Strongly disagree
The Township of Verona does enough to include people with a disability in its policies and practices
Verona is an inclusive community, where everyone can feel welcomed and is able to participate in everything the community offers
In Verona, there are excellent supports and services for individuals with any type of disability to be engaged in the community
The programs and services offered by the community generally meet the needs of all community members
The community is receptive to and supportive of the efforts of local groups advocating to implement policies and programs that meet the needs of individuals with a disability

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* 7. When you are moving around public spaces in Verona, do you have difficulty because of any of the following reasons? (Select all that apply)

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* 8. Which of the following activities have you done in the past 12 months? (Select all that apply.)

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* 9. When thinking about the quality of your life over the next 5 years, please rank the importance of each of these items to you, with 1 being the most important and 8 being the least important. (Write the numbers in the boxes.)

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* 10. Please respond to the following statements about inclusivity in leadership roles and general participation in Verona.

  Strongly agree Agree Neutral Disagree Strongly disagree
People with a disability are welcome to hold leadership and decision-making roles within municipal government in Verona.
I am interested in playing a leadership role in municipal decision-making, but there are accommodation barriers that prevent me from doing so.
When I engage in activities and events in the community, I feel comfortable participating and welcomed by others.
I know who to contact if I have questions or concerns about participating in town positions, activities, or events.

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* 11. Please respond to the following statement:

It is easy for me to access, interpret, and understand announcements and information about events, programs, and services available in the community.

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* 12. If you answered “False” for #11: What is the primary reason it is not easy for you to get information about community events, programs, and services?

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* 13. Please respond to the following statement:

I regularly attend events or casual gatherings and am able to socialize with other community members to my fullest ability.

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* 14. Why do you feel you are unable to socialize to your fullest ability? (Select all that apply.)

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* 15. How easy or difficult is it for you to be included in the following activities in Verona?

  Very easy Easy Neutral Difficult Very difficult
Public events at the Verona Town Square
Verona Library events
Verona Community Center events and programs
Programs offered by the Verona Recreation Department
Multicultural Inclusion Accessibility Advisory Committee (MIAAC) events
Using the community pool, recreation courts and fields, and parks in Verona
Elections voting
Programs at the Montclair YMCA

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* 16. How easy or difficult is it for you to access the following Verona resources?

  Very easy Easy Neutral Difficult Very difficult
Verona Township website
Social media
Verona's CommunityPass and activity registration
Brochure communications about events, resources, and programs
Groups and organizations serving individuals with a disability

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* 17. How easy or difficult is it for you to use the following transportation options?

  Very easy Easy Neutral Difficult Very difficult
Walking
Driving yourself
Having others drive you
Riding a bicycle or electric scooter
A ride service (ex. Uber, Lyft)
The Verona Senior Bus (if applicable)
The Verona Medical Transport Shuttle (if applicable)
NJ Transit bus service)

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* 18. Which of the following transportation enhancements would you use? (Select all that apply.)

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* 19. What prevents you from joining in activities, such as events, workshops, and classes? (Select all that apply)

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* 20. What types of health promotion measures do you feel the community needs to create or provide more of? (Select all that apply.)

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* 21. Are you satisfied with the level of assistance available to help you with tasks outside your home that you might find difficult to complete due to your disability or physical limitations?

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* 22. If you answered “No” for #21: For what types of tasks are you not satisfied with the level of assistance available? (Select all that apply.)

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* 23. What is your gender?

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* 24. What is your ethnicity?

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* 25. What is your approximate average household income?

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* 26. Have you been identified as having any of the following disabilities? (Select all that apply.)

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* 27. Are you a Veteran?

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* 28. If you answered “Yes” for #27: Do you have a disability status assigned by the U.S. Department of Veterans Affairs?

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* 29. If you answered "Yes" for #28: What is your disability rating?

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* 30. Do you participate in New Jersey’s Supplemental Nutrition Assistance Program (NJ SNAP)?

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* 31. Are you homebound?

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* 32. Do you participate in the following state-administered programs? (Select all that apply.)

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* 33. In what areas, if any, is your housing struggling financially? (Select all that apply).

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* 34. Do you have any concerns about health and inclusivity in your community that this survey has not addressed? If yes, please specify.

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* 35. Please tell us if you would be interested in further participating in Verona’s Inclusive Healthy Communities initiative by attending meetings, volunteering, receiving additional information or participating in a focus group or interview. (If yes, please provide your contact information on the next page.) (Select all that apply.)

Contact Information.

Providing this information is entirely optional. This information will only be used to contact you in relation to the Verona Inclusive Healthy Communities initiative. Your survey responses will remain anonymous, even if you choose to provide this information.

Provide this information if you would like to participate in a focus group session or interview, or if you are interested in participating in other ways.

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* 36. Name

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* 37. Email Address

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* 38. Phone Number

Contact information will not be associated with survey responses and will not be shared or used for other purposes.
Thank you very much for completing this survey.
Your assistance in providing this information will help shape Verona's Inclusive Healthy Communities Initiative.

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