Peer Mentor Activity Survey

As ACCESS to Independence works to improve access to peer support, we are interested in knowing if people with disabilities and their families, friends, and supporters, are interested in participating in any groups, events, or activities where people can get together to have fun, provide mutual support, learn new things, or work on issues together. We understand that, at the present time, we have to find ways of connecting people safely, and for now that may mean virtually. But we want to start helping to build community and mutual support in whatever ways we can, now and in the future.

With that in mind, we are interested in understanding what activities ACCESS might help to get started for people with disabilities. On this survey, you will be asked about activities that ACCESS may be able to provide in the future, or connect you with in the community.

Your participation is voluntary, and responses are completely confidential. You have the right to withdraw at any point, for any reason. If you would like to contact the coordinator of this survey, please call Tracy Miller at 608-716-7101, or email her at tracym@accesstoind.org with any questions

This survey should take approximately 10 minutes to complete, and you will receive a huge thank you for sharing your ideas with us. By clicking the button below, you acknowledge that your participation is voluntary, and that you are aware that you may choose to withdraw at any time, for any reason.

Please note that this survey will be best displayed on a laptop or desktop computer. Some features may be less compatible for use on a mobile device.

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* 1. I am a

Person with a disability

Family member

Friend

Supporter

Interested community member

Prefer not to disclose

Other (please specify)

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* 2. My age is

Prefer not to answer

Or please specify your age here

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* 3. My race is

Black or African American

White

Native American or Asian/Pacific Islander

More than one

Prefer not to disclose

Other (please specify)

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* 4. My gender identity is

Female

Male

Prefer not to disclose

LGTBQ+ (please specify)

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* 5. I live in

Madison, WI

Dane County, outside of Madison

Columbia County

Dodge County

Green County

Other County or Community (please specify)

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* 6. Please check any groups or events that you, or someone you support might be interested in attending at ACCESS or other places in the community if hosted by ACCESS

Group for Women with Disabilities

Group for Men with Disabilities

Group for LGBTQ+ People with Disabilities

Group for Youth with Disabilities

Advocacy Group to work on local and/or State and Federal issues

Book Club

Movie Time

Gaming Time

Art and Craft Group

Presentations on Different Topics (please specify below in the other field)

Mutual support for specific issues or groups (please specify below in the other field)

Wellness workshops

Informal Social Gathering

Pot Luck

Other (please specify)

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* 7. What two times a day would you, or the person you support, be most interested in attending group or events?

Late Morning

Lunch Time

Afternoon

Evening

Weekend

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* 8. What locations would be best for any potential events/activities (Please select all that apply)

ACCESS office (3810 Milwaukee St, Madison)

Other Madison East location

Madison West location

Other community in Dane, Dodge, Green or Columbia County (please list)

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* 9. I believe that there are enough support groups, available for people with disabilities in my area

Yes

Not sure

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* 10. I believe that there are enough social groups available for people with disabilities in my area.

Yes

Not sure

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* 11. I believe that there are enough learning activities available for people with disabilities in my area

Yes

Not sure

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* 12. I would like more information interest specific groups available for people with disabilities

Yes, please

No, thank you

Not sure

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* 13. I would like more information about social groups available for people with disabilities

Yes, please

No, thank you

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* 14. I would like to help start a support or social group for people who share my disability.

Yes

I might consider it, if other people were interested

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* 15. I would like to help start a support\social group for people who share my hobbies\interests

Yes

I might consider it, if others were interested

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* 16. I would like to help start an advocacy group for people with disabilities to work on important issues in my community.

Yes

I might consider it, if others were interested

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* 17. I am interested in volunteering to provide one-on-one peer support to someone else with a disability.

Yes

I might consider it, if others were interested

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* 18. If you answered “YES,” or that you might consider it, to any of questions 12 to 17 above, PLEASE PROVIDE US WITH YOUR NAME AND CONTACT INFORMATION below, so that we can follow up with you.

Thank you for sharing your opinions and ideas with us!

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 19. Preferred method of contact (check all that apply)

Phone

Mail

Peer Mentor Activity Survey

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* 1. I am a

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* 2. My age is

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* 3. My race is

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* 4. My gender identity is

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* 5. I live in

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* 6. Please check any groups or events that you, or someone you support might be interested in attending at ACCESS or other places in the community if hosted by ACCESS

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* 7. What two times a day would you, or the person you support, be most interested in attending group or events?

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* 8. What locations would be best for any potential events/activities (Please select all that apply)

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* 9. I believe that there are enough support groups, available for people with disabilities in my area

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* 10. I believe that there are enough social groups available for people with disabilities in my area.

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* 11. I believe that there are enough learning activities available for people with disabilities in my area

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* 12. I would like more information interest specific groups available for people with disabilities

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* 13. I would like more information about social groups available for people with disabilities

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* 14. I would like to help start a support or social group for people who share my disability.

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* 15. I would like to help start a support\social group for people who share my hobbies\interests

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* 16. I would like to help start an advocacy group for people with disabilities to work on important issues in my community.

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* 17. I am interested in volunteering to provide one-on-one peer support to someone else with a disability.

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* 18. If you answered “YES,” or that you might consider it, to any of questions 12 to 17 above, PLEASE PROVIDE US WITH YOUR NAME AND CONTACT INFORMATION below, so that we can follow up with you.Thank you for sharing your opinions and ideas with us!

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* 19. Preferred method of contact (check all that apply)

* 18. If you answered “YES,” or that you might consider it, to any of questions 12 to 17 above, PLEASE PROVIDE US WITH YOUR NAME AND CONTACT INFORMATION below, so that we can follow up with you.

Thank you for sharing your opinions and ideas with us!