Cultural Diversity Public Outreach Survey

Question Title

* 1. What services do you or your family member receive from VMRC?

Behavioral Services

Community Care Home/ICF/etc.

Day Program

Early Start Services

Employment Services

Respite

Tele-Medicine

Transportation

Other (please specify)

Question Title

* 2. Do you feel these services are adequate for you or your family member

Yes

No

Other (please specify)

Question Title

* 3. Are you satisfied with the help your Service Coordinator provides to you and your family?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

Question Title

* 4. How can VMRC better assist you or your family member to meet their needs and goals?

Question Title

* 5. Which race/ethnicity best describes you? (Please choose only one.)

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Mixed Race

Question Title

* 6. What county do you reside?

Amador

Calaveras

San Joaquin

Stanislaus

Tuolumne

Other (please specify)

Question Title

* 7. If you have a need for another language or question about survey please contact Cultural Specialist Carlos Hernandez 209-955-3380 or indicate below your preferred language or question.