1.) Do you have a permanent disability that affects your ability to live independently? Yes No

Is your disability.... Cognitive Psychiatric Physical Sensory (e.g. visual, hearing)

Other

2.) Have you used or are you aware of informational or referral services offered by the independent living service organizations below?

Aware Used -- PARI Independent Living Center

Aware Used -- Ocean State Center for Independent Living (OSCIL)

Aware Used -- Office of Rehabilitations Services, Family Vocational Rehabilitation, State Services for the Blind

Aware Used -- Other (please specify)

3.) Where do you generally get your information about services for living independently?

Internet Television Library Radio Newspapers Magazines Doctors Social Workers

Community Based Organizations Relatives

4.) Please prioritize your top needs below that help you to better live independently? Rank top three then check all others that may apply.

Primary need Please Select One Job Skills Training Independent living skills training Information and referral services Peer Support (contact with similar situations) Services to modify your home for accessibility Personal care services provided in the home or community Accessible transportation Interpreter services for language barriers Sign language interpreters Services coordinated for you An advocate educating the community about disability related issues Accessible recreational opportunities

Secondary need Please Select One Job Skills Training Independent living skills training Information and referral services Peer Support (contact with similar situations) Services to modify your home for accessibility Personal care services provided in the home or community Accessible transportation Interpreter services for language barriers Sign language interpreters Services coordinated for you An advocate educating the community about disability related issues Accessible recreational opportunities

Third need Please Select One Job Skills Training Independent living skills training Information and referral services Peer Support (contact with similar situations) Services to modify your home for accessibility Personal care services provided in the home or community Accessible transportation Interpreter services for language barriers Sign language interpreters Services coordinated for you An advocate educating the community about disability related issues Accessible recreational opportunities

Are your needs met in these areas, yes /no?

Yes No -- Job skills training
Yes No -- Independent living skills training
Yes No -- Information and referral services
Yes No -- Peer support (contact with people who experience the same issues as you)
Yes No -- Services to modify your home for accessibility
Yes No -- Personal care services provided in the home or community
Yes No -- Accessible transportation
Yes No -- Interpreter services for language barriers
Yes No -- Sign language interpreters
Yes No -- Services coordinated for you
Yes No -- An advocate educating the community about disability related issues
Yes No -- Accessible recreational opportunities
Yes No -- Other (please fill in)

5.) What are your major barriers to living independently? (check those that apply)

Lack of funding for adaptive equipment
Language barriers
Complicated bureaucratic processes (red tape, many phone calls, etc.)
No advocate
Lack of information/referral sources
Don’t know where to find services
Not enough services for people with my specific disability
Lack of reliable transportation
Other (Please fill in)

6.) What do you think would make it easier for Rhode Islanders with disabilities to live independently?

7) What is your approximate total household income?

<$20K
$20K - $49K
$50 - $74K
$75 - $150K
> $150 K

8.) What is your home zip code?

9.) Gender -- Male Female

10.) What is your AGE?

<21
22 - 35
36 - 45
46 - 60
> 60

10.) Primary language spoken at home?