2006 QUINCY AREA DISABILITY NEEDS ASSESSMENT Please complete (only 1 survey) from the viewpoint of a person with a disability
DEMOGRAPHICS
1. Your Age
3. Where do you live?
4. Are You a person with a disability? Yes No
5. How many live in your household including yourself? 1 2 - 3 4 - 5 6 - 7 8 - 9 10+
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WORK & EDUCATION
6. What is your current education level? 0 - 8 9 - 11 12 or GED Some College 2 year Degree
4 year Degree Post Graduate Degree Trade School
7. Do you feel your education level is appropriate for your needs or abilities? Yes No
8. Would you like more education or training? Yes No
9. Do you work? Yes No If yes, how many hours a week?
If not, would you like to work? Yes No
10. How many hours a week would you like to work if you could? 1-10 10 - 20 20 - 30 30 - 40 40+
11. What do you feel keeps you from working as much as you’d like (check all that apply): Not Applicable Lack of Transportation Your Health Child Care Issues Retired Effect on Social Security Benefits Lack of Education/Training
Belief or Expectation Employer Won’t Hire You Because of a Disability
PUBLIC ASSISTANCE
12. Do you receive public assistance or have you in the past year? Yes No If yes, what kind? Food Stamps TANF General Assistance Circuit Breaker LHEAP (Energy) SSI SSDI Child Care Subsidy
Please list any others that apply:
MEDICAL
13. Do you have: Medicaid Medicare Private Insurance HBWD
14. Do you go for regular checkups or do you go as needed? Yes No
15. Do you feel your medical, dental and/or prescription drug needs are being met? Yes No If no, What is not being met and why?
HOUSING
16. What sort of housing do you live in? House Apartment Nursing Home Group Home Other
If you live in a house, do you: Own Rent Purchasing
17. Do you require accessible housing? Yes No
If yes, and you rent, did you have difficulty finding accessible housing? Yes No
TRANSPORTATION
18. Do you ever use public transportation? Yes No
If yes, how many trips per week: 0 - 2 3 - 5 6 or more
19. Is there any place you want to go but can not? Yes No
If yes, where do you want to go and why can you not get there?? Places in Quincy Places in Quincy after hours Places in Adams County Other counties or communities, please list:
MISCELLANEOUS
20. Do you have adequate social/recreational opportunities? Yes No
21. Have you made any emergency preparedness plans? Yes No
22. Do you feel you were ever discriminated against because of your disability?? Yes No
If yes, please describe event:
23. Is there anything else you want to comment on – anything related to disability in your community that you would like to see changed, added to or improved upon? Please elaborate – this is your chance to be heard.
24. Would you like us to contact you and provide you with any info? Yes No What information would you like?
If you answered yes to question 24, please provide your contact information:
