COMMUNITY NEEDS SURVEY
Plain-text master, version 1.0.0. From ILDATA.org/instruments/community-needs/

This file matches the online survey word for word. Answer values for keying a
paper response into the online record appear in square brackets after each
option, for example [rights]. Readers can ignore the brackets.

WHO SHOULD FILL THIS OUT
People with disabilities, family members, caregivers, advocates, and disability service providers. If you are filling this out for someone else, please answer based on your experience with them.

BEFORE YOU START
- It takes about 5 minutes.
- You may skip any question except the first one and the county question.
- Your answers are confidential. They are reported only as counts, never with your name.
- Giving your contact details is optional, and they are kept apart from your answers.
- You can stop at any time. What you have answered so far still counts.

[ ] I understand, and I want to take part [consent=yes]
SECTION 1: ABOUT THIS SURVEY

1.1 Who are you filling out this survey for? (Required)
   Choose one.
   ( ) Myself: I have a disability [self]
   ( ) A family member or person I care for [family]
   ( ) Someone I advocate for or support [advocate]
   ( ) People I serve: as an agency or disability service provider [provider]

SECTION 2: SERVICES YOU NEED

2.1 Which services do you need but are not getting?
   Check all that apply. A box appears under each one you check, in case you want to say more.
   [ ] Rights: Help knowing and speaking up for my rights [rights]
       Tell us more about rights: ______________________________ [cn_unmet_rights_more]
   [ ] Emergencies: Help getting ready for emergencies or disasters [emergencies]
       Tell us more about emergencies: ______________________________ [cn_unmet_emergencies_more]
   [ ] Benefits: Help getting SSI, SSDI, food assistance, or other benefits [benefits]
       Tell us more about benefits: ______________________________ [cn_unmet_benefits_more]
   [ ] Social: Help meeting people and staying connected [social]
       Tell us more about social connection: ______________________________ [cn_unmet_social_more]
   [ ] Work: Help finding or keeping a job [work]
       Tell us more about work: ______________________________ [cn_unmet_work_more]
   [ ] School: Help with education or job training [school]
       Tell us more about school: ______________________________ [cn_unmet_school_more]
   [ ] Housing: Help finding a safe, affordable, accessible place to live [housing]
       Tell us more about housing: ______________________________ [cn_unmet_housing_more]
   [ ] Transportation: Help getting around [transportation]
       Tell us more about transportation: ______________________________ [cn_unmet_transportation_more]
   [ ] Something else [other]
       Tell us what else you need: ______________________________ [cn_unmet_other_more]
   [ ] None: I am getting the services I need [none]

2.2 How hard is it to get the help you need?
   Choose one.
   ( ) Very hard: I cannot get help at all [very_hard]
   ( ) Hard: I get some help, but not enough [hard]
   ( ) Somewhat hard: I get help sometimes [somewhat_hard]
   ( ) Not too hard: I usually get the help I need [not_too_hard]

SECTION 3: WHERE YOU LIVE

3.1 Which county in your state do you live in? (Required)
   If you are answering for someone else, choose their county.
   County: ______________________________ [cn_county = county FIPS code]
   ( ) I do not live in your state [outside]

SECTION 4: STAY IN TOUCH (OPTIONAL)

4.1 Your contact information
   Optional. Only fill this in if you would like someone to follow up with you. Your contact details are stored separately from your answers.
   Name: ______________________________ [contact.name]
   Email: ______________________________ [contact.email]
   Phone: ______________________________ [contact.phone]

4.2 Is there anything else you want us to know?
   ____________________________________________________________
   ____________________________________________________________ [cn_comments]

THANK YOU
Your answers have been recorded. They help the organization running this survey understand what people in your state need and plan Independent Living services around it.

Question identifiers are stable across versions of this instrument so results
pool across organizations and years. See ILDATA.org/standards/question-bank/