The following survey is a tool that the CDRC uses to asses the levels of self determination that people with disabilities have in their current situations.  If you have a disability or know someone who does and you would like to participate in the survey, you can cut and paste the questions into an email message to the project leaders, John@theCDRC.org , kenny@thecdrc.org  or print this page, fill it out, and mail it to

John Sorensen

The Arc of Maryland

49 Old Solomon’s Island Road

Suite 205

Annapolis, MD  21401

We sincerely appreciate your participation.

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(optional) Name of the person who this survey is for?

(optional) Name of the person who is helping to fill it out?

Living/home

1)   Where do you live? Do you own or rent your place?

2)   Are you interested in homeownership?

3)   How much help did you receive from people in choosing where you live?

4)   Do you like the community where you live?

5)   Do you have a roommate?

6)   Was it your choice to have a roommate?

a)    If no, why do you have a roommate?

7)   Was this roommate one that you chose?

Freedom

1)   Can you watch what you want on tv?

2)   Do you have as much freedom as you would like?

3)   Are you able to do fun stuff you want in your free time?

4)   Who decided what your plan to move?

Benefits

1)   Do you live only on SSI or SSDI?

2)   How do you get information on your medical coverage?

3)   Are there limits on how much you can earn in a month and still keep your supports under the waiver?

Relationships

1)   Have you made new friends?

2)   Do you have friends or family that live near you?

Self determination

1)   Do you know what self advocacy is?

a)    If not, do you want information?

b)    If so, are you involved?

2)   Have people helped you get used to your new life and making your own choices?

3)   Are you the boss of who gets paid to help you?

a)    Do you decide when they work?

b)    Do you decide what they do for you?

c)    Do you hire them?

Barriers

Have you had trouble with:

·       Meeting new people?

·       Working?

·       Hanging out with friends?

·       Transportation?

·       Staff/PAs?

·       Finding a place to live?

·       Doing what you want?

Jobs/learning

1)   Are you working?

a)    If not, are you trying to find a job? Or something else to do during the day?

2)   What kind of job would you chose?

3)   Are you afraid of working or looking for a job because you will lose your benefits?

4)   Are you interested in classes or trainings?