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Spinal Cord Injury Survey

For demographic purposes: What best describes your age group?
For demographic purposes: Do you consider yourself:
For demographic purposes: What best describes your annual income?
For demographic purposes: What type of home is your primary residence?
Single Family House
Duplex
Apartment
Townhouse/Condo
Mobile Home
Assisted Living
Nursing Home
Low-income Housing
Other
Please Specify:
Do you have a spinal cord injury, or know someone with a spinal cord injury?
I have a spinal cord injury.
I do not have have a spinal cord injury.
I know someone with a spinal cord injury.
I do not know anyone with a spinal cord injury.
I do not know what a spinal cord injury is.
Do you, or someone that you know, use a wheelchair?
Yes
No
Is your current home ADA/wheelchair accessible?
Yes- fully
Yes- partially
No
I'm not sure
Other
Please Specify:
If you, or someone in your family, became disabled and needed an ADA/wheelchair accesible home, would you:
Remodel our home.
I couldn't afford to remodel.
Move to a new home that is ADA accessible.
Would have to move into an assisted living center or nursing home.
I don't know what I would do.
Other
Please Specify:
Have you had, or do you know anyone who has had experience with an assisted living center?
Yes
No
What has your/their satisfaction been with the assisted living center?
Very Satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very Dissatisfied
N/A
Other
Please Specify:
What did you/they like about the assisted living center?
Staff
Lighting
Restrooms
Accessiblity
Activities
Level of Care
Decorations
N/A
Other
Please Specify:
What did you/they not like about the assisted living center?
Staff
Lighting
Restrooms
Accessiblity
Activities
Level of Care
Decorations
N/A
Other
Please Specify:
What amenities would you like to see in any assisted living center?
Exercise
Indoor Activities
Outdoor Activities
24-hr. Staff and Emergency Calling
Daily Living Services (Bathing, Dressing, Grooming, etc.)
Provided Restaurant-Style Meals and Snacks
Medication Administration
Apartment Maintenance
Housekeeping and Linen Services
Barber or Beauty Shop
Movie Theater
Nutrition Services/Special Diets
Eating Assistance
All utilities, except Phone paid
Alternative payments, like Medicare, Veteran's Aid, Attendance Benefit, Long-Term Insurance, etc.
Recreational Therapy
Occupational Therapy
Physical Therapy
Transportation Provided
Pets Allowed
Full Kitchens
Kitchenettes
Full ADA accessibility
Activity Rooms
Music and Art Classes
Educational Classes
Individually Controlled Heat & A/C in Each Unit
Indoor Common Areas
Outdoor Common Areas
Pool
Hot Tub
Sauna
Gym
Other
Please Specify:
What types of therapy would you be interested in:
Recreational Therapy
Music Therapy
Art Therapy
Occupational Therapy
Physical Therapy
Mental Health Therapies
Holistic/Alternative
Chiropractic
Other
Please Specify:
How far away would you travel from your residence for specialty medical care for yourself, or loved one?
0-10 miles
11-29 miles
30-50 miles
51-75 miles
Over 75 miles
There is no limit
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