The North Carolina Statewide Independent Living Council (NC SILC) and North Carolina’s Centers for Independent Living (CILs) want to learn more about the needs of people with disabilities across our state. Your answers will help improve services, advocacy, and independent living supports in North Carolina.

• This survey is voluntary.
• Your answers are anonymous unless you choose to share your contact information at the end.
• The survey should take about 10 minutes to complete.
If you need help completing this survey or need it in another format, please contact Gloria Garton at gloria.garton@nc-silc.org or call 984-480-6328.
Section 1: About You

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* 1. Which of the following best describes you. (Check all that apply)

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* 2. When answering this survey, you are answering based on:*

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* 3. What disability type best describes you or the person you are answering for? Check all that apply.

Section 2: Independent Living Needs

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* 4. Which programs or services are most important to you to live independently? (Check up to 3)

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* 5. In the past year, what has been the biggest challenge affecting your independence or community participation?

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* 6. What would help improve your ability to live independently?

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* 7. What barriers have you experienced? (Check all that apply)

Section 3: Centers for Independent Living (CILs)

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* 8. Which Center for Independent Living (CIL) are you most familiar with or have most recently used?

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* 9. What is your relationship with a Center for Independent Living?

Section 4: Community Information: The following questions help us understand which communities may need more services and support.

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* 10. What is your age group?

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* 11. Which best describes where you live?

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* 12. What North Carolina county do you live in?

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* 13. What is your ZIP code?

Final Comments

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* 14. Is there anything else you would like us to know?

If you would like someone from a Center for Independent Living to contact you, please provide your information below.

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* 15. Please provide your first and last name.

Please provide us with the preferred method to contact you.

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* 17. Phone Number

Thank you for completing this survey.

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