Developmental Disabilities Task Force

SURVEY OF NEEDS
FOR PERSONS WITH DEVELOPMENTAL DISABILITIES

Instructions

This questionnaire is for persons who:

· have a disability that occurred before the age of 22 and

· do not have a diagnosis of mental retardation.

This is not an application for services. Please complete the questionnaire only once even if you receive more than one copy. This questionnaire is intended to assist the Developmental Disabilities Task Force that was established by the Tennessee legislature to identify needs and to plan for services that are needed by persons who have developmental disabilities other than mental retardation.

INFORMATION ABOUT THE PERSON WITH A DEVELOPMENTAL DISABILITY

1.	I agree to be part of this study. I understand that I may choose to respond or not respond to each question. Also, I may exit without submitting my responses.

Yes

2.	Your Age (in Years)

3.	Your Gender

	Male
	Female

4.	Please select the one ethnic background that best describes you.

	White non-Hispanic
	Black/African-American
	Latino/Hispanic
	Native American
	Asian or Pacific Islander
	Prefer not to identify
	Other:

5.	County in which you live?

6.	Your disability: What is the diagnosis of your primary disability?

7.	Did your disability occur before age 22?

	Yes
	No

Your Living Situation

8.	Do you live ...

	Alone
	With your parent(s)
	With other family members
	With other persons, not family, who are caregivers
	With other persons, not family, who are NOT caregivers
	Other:

9.	My primary caregiver(s) ...

	Myself
	Parent(s)
	Other family members
	Other unpaid persons
	Other paid persons
	Other:

Health and Funding

10.	Health Care: Who pays for you health care?

	(Select all that apply.)
	Receive Medicaid or TennCare (Including EPSDT/TENNderCare)
	Receive Medicare
	Have private health insurance
	No heath insurance
	Other:

11.	Funding for Your Supports?

	(Select all that apply.)
	Do you receive services through the State of Tennessee Family Support Program?
	Are you on the waiting list for the State of Tennessee Family Support Program?
	Do you receive SSI?

12.	Do you receive other funding for support in your home or community? If yes, please describe:

13.	Do you need more services than you are currently receiving? (If yes, complete the next series of questions.)

	Yes
	No

Needed Services

32.	If you need personal support, approximately how many hours per day do you need?

33.	Are there other support needs that you have? (Please put each need on a separate line. Hit the return key to go a new line.)

Other Comments

34.	Other comments about services or assistance that you (or your family) need that you are not currently receiving?

Thank you for taking time to complete this survey.

Your answers to this survey will be anonymous with no personal identifying information.
After you submit your responses to this survey, you will be directed to another secure web page.

If you would like to receive more information about this project, please provide your name and contact information on the next page.

35.	I am done with the survey.

Yes

	Autism Spectrum disorder
	Blind/Visual impairment
	Cerebral Palsy
	Deaf/Hearing Impairment
	Health Impairment
	Neurological Impairment
	Physical Disability
	Spina Bifida
	Spinal Cord Injury
	Traumatic Brain Injury
	Other Condition: