Participant Demographics

Participant Data

Thank you for taking the time to fill out this survey. Your answers help us to better serve the community and leverage important funding for our services. Please fill out this survey from the perspective of the participant. All information is anonymous and confidential. If you are filling out this survey for more than one person, please fill out a separate demographic survey for each individual that experiences I/DD.

Question Title

* 1. Gender

Male

Female

Question Title

* 2. Age

0-4

5-12

12-21

22-35

36-45

46-64

65+

Question Title

* 3. Race/Ethnicity

White

Black or African American

American Indian or Alaska Native

Asian American

Pacific Islander

Hispanic/Latino

Two or more races

Other (please specify)

Question Title

* 4. Disability Type

Autism Spectrum

Intellectual Disability

Down Syndrome

ADHD/ADD

Cerebral Palsy

Hearing Impairment

Vision Impairment

Speech Impairment

Mental Health, Emotional or Behavioral Disorder

Traumatic Brain Injury

Physical Disability

Other (please specify)

Question Title

* 5. Relationship to Participant

Parent

Other Family Member

Paid Caregiver (Foster)

Paid Caregiver (Residential)

Other Paid Professional

Other (please specify)

Question Title

* 6. Household Income - Gross

< $20,000

$20,000 - $40,000

$40,000 - $60,000

$60,000 - $80,000

$80,000+

N/A

Question Title

* 7. Number of People in Household

Question Title

* 8. Household Type

Family - Both parents present

Family - Single parent

Family - non-parent

Foster Home

Residential

Lives alone or independently

Question Title

* 9. Other services being received or accessed by person using services

CDRC

The Child Center

Child Welfare

Developmental Disabilities Services

Direction Services

Early Education Program

EC Cares

Food Boxes

Headstart

Healthy Start

Lane ESD

Medicaid

OHP

`Public Health

Relief Nursery

Senior & Disabled Services

Service Provider (Residential)

(SSI) Social Security Insurance

SSDI (Social Security Disability Income)

Social Security Benefits

SNAP (Food Stamps)

Temporary Assistance for Needy Families (TANF)

Free Lunch Program

Employment-Related Day Care program (ERDC)

Vocational Rehabilitation (VR)

Full Access Brokerage

Mentor Oregon

Housing Authority (HACSA)

Counseling Services

WIC (Women, Infants and Children)

Other (please specify)

Question Title

* 10. What are your greatest barriers in the community?

Access to food

Access to affordable housing

Employment

Access to healthcare

Access to mental health services

Navigating the social services system

Access to affordable childcare

Access to qualified care providers

Other (please specify)