Thank you for agreeing to answer a few questions about your relationship with disABILITY LINK. Your answers will help us to ensure that our services reach our community as effectively as possible. 

* 1. Please enter your name:

* 2. Person responding to survey:

* 3. Sex:

* 4. Age:

* 5. What is your ethnicity? (Please select all that apply.)

* 6. What is your disability? (Please check all that apply.)

* 7. Primary county of residence:

* 8. Where have you noticed disABILITY LINK information in the community? (Please check all that apply):

* 9. Which disABILITY LINK service(s) have you used? (Please check all that apply)

disABILITY LINK’s goal is to help you to increase or maintain your independence and skills. We do this by helping you identify choices and community supports and by advocating on your behalf. Please rank the following statements based on your satisfaction with disABILITY LINK services. This survey is voluntary and confidential. Please express yourself freely.

 Please circle the response that best represents your experience and include an explanation or an example. This is your disABILITY LINK. Your comments are very important. This is especially true if you indicate Strongly Agree or Strongly Disagree. If you have mixed feelings about a topic, please make a choice; then describe the mixed experience. Questions about “staff” do not apply to personal assistants who are employed through the Consumer Employer / Fiscal Agent model.

Thank you for sharing your experience.

* 10. When I contact disABILITY LINK, they respond in a timely manner.

* 11. disABILITY LINK staff treat me with dignity and respect, and as a peer.

* 12.  disABILITY LINK staff demonstrate understanding of my unique needs and hopes.

* 13. There is clear communication between disABILITY LINK office staff and me.

* 14. I am satisfied with the professional and positive attitude disABILITY LINK staff show toward me.

* 15. disABILITY LINK office staff are well-informed about community resources. They provided me with appropriate information and referrals about disability-related issues and services.

* 16. The information and referrals I received met my needs.

* 17.  I feel that I am in charge of the services I receive from disABILITY LINK.

* 18. The services I receive through disABILITY LINK help me to gain/maintain my independence.

* 19. I have new skills, new knowledge, or new resources since I began working with disABILITY LINK.

* 20. I have become more independent or I have more choices since I began working with disABILITY LINK.

* 21. I am more comfortable expressing my needs or expecting equal treatment in my community since I began working with disABILITY LINK.

* 22. I have tried to advocate for others more or with greater confidence since I began working with disABILITY LINK.

* 23. I am satisfied with disABILITY LINK’s advocacy efforts on issues that concern people with disabilities.

* 24. I would recommend disABILITY LINK services to someone I care about.

* 25. I primarily worked with this staff member:

* 26. I would like to learn more about these services:

* 27. The services I received helped me to avoid living in a nursing home or helped me to transition from a nursing home or other institution back into the community of my choice.

* 28. If you would like to have a confidential discussion about an issue related to your quality of service, please provide us with the best way to contact you.