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INSILC Public Input Survey

The estimated time to complete this form is about seven minutes. You may take longer if you would like to provide more detailed comments. To complete this form in another format or language, or to request assistance or communication accommodation, call 1-844-446-7452 or email Info@IndianaSILC.org.
1.How did you hear about this survey?
2.Which best describes your role in providing this feedback? Choose one.
3.Whose experience is this feedback mainly about? Choose one.
4.Which Indiana county or area is this feedback mainly about? Choose one.
5.What are you sharing today? Select all that apply.
6.What area or areas does your feedback concern? Select all that apply.
7.What would you like us to know? You may describe a need, barrier, idea, concern, positive experience, or something that is working well.
Please do not include names, addresses, case numbers, medical records, or other information that could identify you or another person. Responses may be summarized publicly. Comments will not be quoted publicly without your permission and will be reviewed to remove any identifiable information.
8.What made it difficult to get the services, supports, or opportunities described in your feedback? Select all that apply.
9.What change would most improve this situation:
10.How much did this issue affect the person involved?
11.How often has this issue occurred?
12.How urgent is this issue?
13.Who is primarily affected by this issue?  Select all that apply.
14.What would you like INSILC to do with your feedback? Select all that apply.
15.May INSILC quote your comments in reports, presentations, or public materials after removing your name and other identifying details?
Your contact information will be used only to follow up on this submission. It will not be included in public reports, quotations, or summaries.