Bringing

Independence

To Texas

Give a general description of the Needs Assessment Survey instrument. Also assure the site visitor that the information gathered will be used as a general measurement for consumer needs. Information that identifies you with this survey will NOT be requested or stored.

Provide some additional assurances here if needed.

Here's the survey.

Location Data

Consumer Data



ISSUE [1.]: Housing

Check all boxes that you beleive describe needs in your community (Note: you may check multiple boxes.)

ISSUE [2.]: Employment

Check all boxes that you beleive describe needs in your community (Note: you may check multiple boxes.)

ISSUE [3.]: Transportation

Check all boxes that you beleive describe needs in your community (Note: you may check multiple boxes.)

ISSUE [4.]: Education

Check all boxes that you beleive describe needs in your community (Note: you may check multiple boxes.)

ISSUE [5.]: Communications

Check all boxes that you beleive describe needs in your community (Note: you may check multiple boxes.)

ISSUE [6.]: Assistive Technology

Check all boxes that you beleive describe needs in your community (Note: you may check multiple boxes.)

ISSUE [7.]: Health Care and Personal Assistance

Check all boxes that you beleive describe needs in your community (Note: you may check multiple boxes.)

Ratings

Rate these issues in order of importance to you. Base your rating on a simple scaling system where 1 is the most important and 7 is least important.

Open Comment

You're Done!