1. INTRODUCTION SILC is conducting a survey to collect information about disability related programs and services that provide opportunities for people with disabilities to live independently in their community. The information collected will assess how those programs and services are meeting the needs of people with disabilities living Arizona. The results of the survey will provide SILC with statistical and other information data necessary to work with advocates and policy makers to create new programs, enhance, and revise current programs assisting Arizonans with disabilities. Your participation in the process, therefore, is important. Please complete the attached survey. SILC wants to hear directly from people with disabilities, their family members, friends, care attendants, or other stakeholders. Don’t hesitate to express your thoughts and ideas about what is needed and how to improve living in Arizona with a disability. Please feel free to answer the questions as you like and skip any you feel uncomfortable about. The information you share in the survey will remain confidential. SILC will not use or attach any names to any information in the report. And remember, there are no wrong answers. Thank you for taking the time to share your thoughts and ideas. This material is available in alternate formats. If you would like to request an alternate format or for any questions please contact Tony DiRienzi, at 602-262-2900 or via email at tony@azsilc.org. AZ SILC, The Disability Empowerment Center, 5025 E Washington Street, Suite 214, Phoenix AZ 85034 2. IDENTIFY SURVEY TAKER Please identify yourself: Person with a disability Parent of a minor or guardian of an adult with a disability Family member/partner of an adult with a disability Friend/ personal assistant of an adult with a disability Community advocate/service provider Other (please specify) 3. GENERAL FEELINGS Below is a list of statements dealing with your general feelings about yourself as a person with a disability. Please check the answer that best describes how you feel about yourself. a. In general I am satisfied with my life. Strongly Agree Agree Disagree Strongly Disagree b. In general my physical health is good. Strongly Agree Agree Disagree Strongly Disagree c. I am able to live independently. Strongly Agree Agree Disagree Strongly Disagree d. I am able to maintain and stay within my budget. Strongly Agree Agree Disagree Strongly Disagree e. I can get the medical attention I need. Strongly Agree Agree Disagree Strongly Disagree f. I am happy in my current living situation. Strongly Agree Agree Disagree Strongly Disagree g. I receive the social and emotional support I need. Strongly Agree Agree Disagree Strongly Disagree h. I participate in and feel connected to my community. Strongly Agree Agree Disagree Strongly Disagree i. I am able to access the services I need. Strongly Agree Agree Disagree Strongly Disagree j. I have adequate opportunity to be involved in the community. Strongly Agree Agree Disagree Strongly Disagree k. I feel people have a good understanding of disability. Strongly Agree Agree Disagree Strongly Disagree l. I feel discriminated against because of my disability. Strongly Agree Agree Disagree Strongly Disagree 4. DEMOGRAPHICS PLEASE RESPOND TO THE DEMOGRAPHIC AS A DESCRIPTION OF THE PERSON WITH A DISABILITY. What is your gender? Male Female What is your disability? You may check more than one. Cognitive Mental Physical Sensory – Hearing Sensory – Vision What is your age? Under 5 5 to 15 16 to 24 25 to 44 45 to 64 65 years and over How would describe your ethnicity? Check all that apply. American Indian or Alaska Native Asian Black/African American Caucasian Hispanic/Latino Native Hawaiian Other (please specify) ________________________________ What is your annual household income? Prefer not to answer $0-$9,999 $10,000-$19,999 $20,000-$29,999 $30,000-$39,999 $40,000-$49,999 $50,000-$59,999 $60,000-$69,999 $70,000 or more How would you describe your living arrangement? Live alone With spouse/partner With parents With Children With relative(s) or friend(s) With unrelated person(s) such as an attendant or housekeeper Group home Mental Health Facility Nursing home/skilled care facility Assisted Living Facility No fixed address – homeless Other please specify What is the highest educational level or years in school you completed? No formal schooling Elementary education (1-8) Secondary education, no diploma (9-12) Special education certificate/diploma High school diploma or GED Associate degree or vocation certificate Bachelors degree Masters degree or higher What is your current employment status? Never employed Self employed Employed part-time (31 hours per week or less) Employed full-time (32 hours per week or more) Out of work for more than 1 year Out of work for less than 1 year A student Retired Are you a veteran? Yes No 5. SERVICES Please answer 'Yes' or 'No' to indicate whether you have needed any of the following services in the past 6 months. Answer all that apply. a. Advocacy / Legal Services b. Assistive Technology c. Behavioral Health Services d. Benefits Assistance e. Communications Assistance f. Emergency/Safety Services g. Employment/Vocational Services h. Health Care i. Home Modifications j. Housing k. Independent Living Skills Training l. Information and Referral m. Interpreter Services n. Mobility Training o. Nursing Home Transition Assistance p. Peer Support q. Personal Assistance Services r. Personal Transportation s. Temporary Emergency Shelter t. Transportation Services u. Other please specify Please answer 'Yes' or 'No' to indicate whether you have received any of the following services in the past 6 months. Check all that apply a. Advocacy / Legal Services b. Assistive Technology c. Behavioral Health Services d. Benefits Assistance e. Communications Assistance f. Emergency/Safety Services g. Employment/Vocational Services h. Health Care i. Home Modifications j. Housing k. Independent Living Skills Training l. Information and Referral m. Interpreter Services n. Mobility Training o. Nursing Home Transition Assistance p. Peer Support q. Personal Assistance Services r. Personal Transportation s. Temporary Emergency Shelter t. Transportation Services u. Other please specify 6. UTILIZING SERVICES AND PROGRAMS Have you ever used services from any of the following? Answer all that apply. American Association of Retired Persons (AARP) Area Agency on Aging Arizona Bridge to Independent Living (ABIL) in Phoenix Arizona Center for Disability Law (ACDL) Arizona Commission for the Deaf and Hard of Hearing (ACDHH) Arizona Department of Education Arizona Department of Health Services (ADHS) Arizona Disability Advocacy Coalition Arizona Health Care Cost Containment System (AHCCCS) Arizona Spinal Cord Injury Association (AZSCI) Arizona Multiple Sclerosis Association ASSIST! To Independence in Tuba City CyberCIL on the Internet DIRECT in Tucson Independent Living Rehabilitation Services Native American Tribal Communities New Horizons in Flagstaff and Prescott SMILE in Yuma Veterans Administration Vocational Rehabilitation Other please specify 7. VOTE Did you vote in the last election? Yes Not registered to vote Not eligible to vote No 8. GREATEST NEEDS OF ARIZONAN WITH DISABILITIES What do you believe are the greatest needs of Arizonans withdisabilities? Please check the answer that best reflects what you believe. a. Advocacy/Legal Services Not a Needat All A Little Need A Moderate Need A Significant Need b. Assistive Technology Not a Needat All A Little Need A Moderate Need A Significant Need c. Behavioral Health Services Not a Needat All A Little Need A Moderate Need A Significant Need d. Benefits Assistance Not a Needat All A Little Need A Moderate Need A Significant Need e. Communications Assistance Not a Needat All A Little Need A Moderate Need A Significant Need f. Emergency Services Not a Needat All A Little Need A Moderate Need A Significant Need g. Employment services Not a Needat All A Little Need A Moderate Need A Significant Need h. Health Care Not a Needat All A Little Need A Moderate Need A Significant Need i. Home Modifications Not a Needat All A Little Need A Moderate Need A Significant Need j. Housing Not a Needat All A Little Need A Moderate Need A Significant Need k. Independent Living Skills Training Not a Needat All A Little Need A Moderate Need A Significant Need l. Information and Referral Not a Needat All A Little Need A Moderate Need A Significant Need m. Interpreter Services Not a Needat All A Little Need A Moderate Need A Significant Need n. Mobility Training Not a Needat All A Little Need A Moderate Need A Significant Need o. Nursing Home Transition Assistance Not a Needat All A Little Need A Moderate Need A Significant Need p. Peer Support Not a Needat All A Little Need A Moderate Need A Significant Need q. Personal Assistance Services Not a Needat All A Little Need A Moderate Need A Significant Need r. Personal Transportation Not a Needat All A Little Need A Moderate Need A Significant Need s. Temporary Emergency Shelter Not a Needat All A Little Need A Moderate Need A Significant Need t. Transportation Services Not a Needat All A Little Need A Moderate Need A Significant Need u. Other please specify Not a Needat All A Little Need A Moderate Need A Significant Need Where is your home (person with a disability) or office (professional)? Zip Code Tribal Community Name Other OPTIONAL: In the future the Arizona Statewide Independent Living Council may conduct more comprehensive and detailed assessments related to specific areas of the data from this survey instrument. We are collecting contact information of people who would like to participate in our future assessments; this information is for internal use only and will not be otherwise distributed. Name: Address City/State/Zip Email Comments: Thank you Arizona Statewide Independent Living Council (SILC) 2011 Needs Assessment 1