**APPENDIX A**

**EVALUATION PANEL OF EXPERTS**

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# APPENDIX A

Independent Living Evaluation Panel of Experts

+-----------------------------------+-----------------------------------+
| Elmer C. Bartels,                 | Tom Driscoll\                     |
|                                   | Massachusetts Assistive           |
| Commissioner                      | Technology Partnership\           |
|                                   | Children\'s Hospital\             |
| Massachusetts Rehabilitation      | 1295 Boylston Street, Suite 310\  |
| Commission                        | Boston, MA 02215\                 |
|                                   | (617) 355-7820                    |
| 4 Point Place                     |                                   |
|                                   | \(617\) 355-7301 (TTY)            |
| 27-43 Wormwood Street             |                                   |
|                                   | \(617\) 355-6345 (Fax)            |
| Boston, MA 02210-1606             |                                   |
|                                   | [**driscoll@cape                  |
| \(617\) 204-3600                  | .com**](mailto:driscoll@cape.com) |
|                                   |                                   |
| \(617\) 727-1354 (Fax)            | Lex Frieden                       |
|                                   |                                   |
| <elmer.c.bartels@state.ma.us>     | Senior Vice President, TIRR       |
|                                   |                                   |
| Michael Blatchford                | Director, Independent Living      |
|                                   | Research Utilization              |
| Vice President                    |                                   |
|                                   | 1333 Moursund                     |
| Assist! to Independence           |                                   |
|                                   | Houston, TX 77030-3405            |
| P.O. Box 4133                     |                                   |
|                                   | \(713\) 797-5283                  |
| Tuba City, AZ 86045               |                                   |
|                                   | \(713\) 797-5790 (TDD)            |
| \(928\) 283-6261                  |                                   |
|                                   | \(713\) 799-7095 (Fax)            |
| \(928\) 283-6672 (Voice/TTY)      |                                   |
|                                   | lfrieden@bcm.tmc.edu              |
| \(928\) 283-6284 (Fax)            |                                   |
|                                   | Devva Kasnitz, Ph.D.              |
| assist@cybertrails.com            |                                   |
|                                   | 108 Dunaway Court\                |
| Joe Bravo                         | Fortuna, CA 95540\                |
|                                   | (707) 443-1973/ 707-725-9218\     |
| Executive Director                | [**devva@earthlink.n              |
|                                   | et**](mailto:devva@earthlink.net) |
| Westchester Independent Living    |                                   |
| Center                            | Mark Obatake                      |
|                                   |                                   |
| 200 Hamilton Avenue               | Executive Director                |
|                                   |                                   |
| White Plains, NY 10601            | Hawaii Independent Living Center  |
|                                   |                                   |
| \(914\) 682-3926                  | 414 Kuwili Steet, Suite 102       |
|                                   |                                   |
| \(914\) 682-8518 (Fax)            | Honolulu, HI 96817                |
|                                   |                                   |
| <Jbravo297@aol.com>               | \(808\) 522-5400 (V/TTY)          |
|                                   |                                   |
| Michael Collins,\                 | \(808\) 522-5327 (Fax)            |
| Executive Director\               |                                   |
| Statewide Independent Living      | [**moba                           |
| Council\                          | take@DiverseAbilities.org**](mail |
| 1600 K Street, Suite 100\         | to:mobatake@DiverseAbilities.org) |
| Sacramento, CA 95814\             |                                   |
| (916) 445-0142                    | Ralph Shelman\                    |
|                                   | Peninsula CIL\                    |
| \(916\) 445-5627 (TTY)            | 2021 B Cunningham Drive, Suite 2\ |
|                                   | Hampton, VA 23666\                |
| \(916\) 445-5973 (Fax)            | (757) 827-0275                    |
|                                   |                                   |
| <mcollins@calsic.org>             | \(757\) 827-0275 TTY              |
|                                   |                                   |
| Tom Osborn, APRIL representative  | \(757\) 827-0655 FAX\             |
|                                   | Iepcil@aol.com                    |
| Executive Director                |                                   |
|                                   | Nancy Ward                        |
| NCILS, Inc.                       |                                   |
|                                   | Self-Advocacy Coordinator         |
| 1120 25 Avenue                    |                                   |
|                                   | Oklahoma People First             |
| Black Eagle, MT 59414             |                                   |
|                                   | 16 E. 16^th^, Suite 405           |
| \(406\) 452-9834                  |                                   |
|                                   | Tulsa, OK 74119-447               |
| \(800\) 823-6245 (V/TDD)          |                                   |
|                                   | \(918\) 582-8272                  |
| \(406\) 453-3940 (Fax)            |                                   |
|                                   | \(918\) 582-3628 (Fax)            |
| <osbncils@valcom.net>             |                                   |
|                                   | nwardopf@hotmail.com              |
| Laura Rauscher\                   |                                   |
| Disability Services Director/ADA  |                                   |
| Coordinator\                      |                                   |
| Office of Disability Services\    |                                   |
| Smith College\                    |                                   |
| College Hall Room 3\              |                                   |
| Northampton, Massachusetts 01063  |                                   |
|                                   |                                   |
| \(413\) 585-2071                  |                                   |
|                                   |                                   |
| \(413\) 585-2072 (TTY)\           |                                   |
| (413) 585-2206 (Fax)              |                                   |
|                                   |                                   |
| lrausche@eunice.smith.edu         |                                   |
|                                   |                                   |
| Lee Schulz, NCIL Representative   |                                   |
|                                   |                                   |
| Executive Director                |                                   |
|                                   |                                   |
| Independence FIRST                |                                   |
|                                   |                                   |
| 600 West Virginia Street, Suite   |                                   |
| 300                               |                                   |
|                                   |                                   |
| Milwaukee, WI 53204               |                                   |
|                                   |                                   |
| \(414\) 291-7520 (V/TTY)          |                                   |
|                                   |                                   |
| \(414\) 291-7525 (Fax)            |                                   |
|                                   |                                   |
| [**lee@independencefirst.org**](  |                                   |
| mailto:lee@independencefirst.org) |                                   |
+-----------------------------------+-----------------------------------+

**APPENDIX B**

**TABLES**

Appendix B

**Table B-1. Service received by CIL location**

  -------------------------------- ----------- ----------- ----------- ---------
                                   Overall     CIL                     
                                               location\               
                                               (% of CILs              
                                               in Consumer             
                                               Survey)                 

                                               Rural\      Suburban\   Urban\
                                               (15%)       (3%)        (75%)

  Service                          \%                                  
                                   consumers                           
                                   receiving                           
                                   service                             

  Benefits advisement              41          51          36          39

  Getting technology or adaptive   26          36          26          24
  equipment                                                            

  Information and referral         59          60          63          58

  Peer support                     37          32          44          37

  ADA training                     29          23          33          30

  Home modification                26          24          29          26

  Employment advisement            20          10          26          21

  Independent living skills        20          16          21          20
  training                                                             

  Housing referral or assistance   26          9           28          29

  Personal assistance services or  29          25          23          31
  referral                                                             

  Transportation                   19          18          17          20

  Transition from school to work   9           4           9           10
  -------------------------------- ----------- ----------- ----------- ---------

**Table B-2. Consumer satisfaction with services received by income
level**

+--------------------+-------+-------+-------+-------+-------+-------+
|                    |       | I     |       |       |       |       |
|                    |       | ncome |       |       |       |       |
|                    |       | level |       |       |       |       |
|                    |       | (%    |       |       |       |       |
|                    |       | consu |       |       |       |       |
|                    |       | mers) |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+
|                    | Ov    | \<\$8 | \$    | \$1   | \$2   | \$40  |
|                    | erall | ,000\ | 8,001 | 0,001 | 0,001 | ,000+ |
|                    |       | (39%) | -\$10 | -\$20 | -\$40 |       |
|                    |       |       | ,000\ | ,000\ | ,000\ | (6%)  |
|                    |       |       | (17%) | (25%) | (14%) |       |
+--------------------+-------+-------+-------+-------+-------+-------+
| Service            | \%    |       |       |       |       |       |
|                    | very  |       |       |       |       |       |
|                    | sati  |       |       |       |       |       |
|                    | sfied |       |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+
| Transition from    | 74    | 93    | 62    | 62    | 93    | 57    |
| school to work     |       |       |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+
| Peer support       | 62    | 77    | 65    | 48    | 55    | 47    |
+--------------------+-------+-------+-------+-------+-------+-------+
| Benefits           | 63    | 73    | 57    | 58    | 32    | 73    |
| advisement         |       |       |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+
| Information and    | 64    | 69    | 61    | 65    | 65    | 56    |
| referral           |       |       |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+
| ADA training       | 71    | 61    | 86    | 84    | 73    | 56    |
+--------------------+-------+-------+-------+-------+-------+-------+
| Personal           | 74    | 71    | 77    | 82    | 70    | 73    |
| assistance         |       |       |       |       |       |       |
| services or        |       |       |       |       |       |       |
| referral           |       |       |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+
| Home modification  | 75    | 81    | 70    | 82    | 62    | 62    |
+--------------------+-------+-------+-------+-------+-------+-------+
| Transportation     | 87    | 91    | 82    | 83    | 93    | 34    |
+--------------------+-------+-------+-------+-------+-------+-------+
| Getting technology | 73    | 61    | 80    | 78    | 88    | 61    |
| or adaptive        |       |       |       |       |       |       |
| equipment          |       |       |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+
| Independent living | 69    | 77    | 57    | 57    | 95    | 100   |
| skills training    |       |       |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+
| Housing referral   | 65    | 70    | 61    | 47    | 69    | 79    |
| or assistance      |       |       |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+
| Employment         | 59    | 62    | 38    | 62    | 39    | 63    |
| advisement         |       |       |       |       |       |       |
+--------------------+-------+-------+-------+-------+-------+-------+

**Table B-3. Service received by age group**

  -------------------------- ---------- ------------ -------- -------- -------- -------
                                        Age Group (%                            
                                        consumers)                              

                             Overall    \<18\        18-24\   25-44\   45-64\   65+\
                                        (5%)         (8%)     (36%)    (39%)    (13%)

  Service                    \% service                                         
                             received                                           

  Information and referral   59         46           66       60       62       45

  Employment advisement      20         7            51       26       15       1

  Independent living skills  20         8            48       24       16       6
  training                                                                      

  Peer support               37         31           45       39       43       14

  Personal assistance        29         17           39       31       29       26
  services or referral                                                          

  Transition from school to  9          23           37       8        4        2
  work                                                                          

  Transportation             19         11           26       21       19       12

  Benefits advisement        41         21           41       47       44       23

  Housing referral or        26         **.**        23       34       26       16
  assistance                                                                    

  ADA training               29         15           24       33       36       7

  Home modification          26         28           22       23       29       24

  Getting technology or      26         16           33       24       24       39
  adaptive equipment                                                            
  -------------------------- ---------- ------------ -------- -------- -------- -------

**Table B-4. Type of change in life (% of consumers)**

  ----------------- ----- --------- ------------ ------------ ----- -------------- --------- ------------ -------- ---------------- ------------ -----------
  Service           I&R   Peer      Benefits     Personal     ADA   Home           Housing   Employment   IL       Transportation   Transition   Assistive
                          support   advisement   assistance         modification                          skills                    from school  devices
                                                                                                                                    to work      

  **Reported                                                                                                                                     
  change**                                                                                                                                       

  Self-perception   19    42        14           12           28    2              3         13           8        8                9            2

  IL skills         2     4         8            7            1     11             3         6            68       2                5            3

  General           17    4         9            24           4     25             9         5            9        15               21           14
  independence                                                                                                                                   

  Get around        5     5         1            \-           3     4              1         \-           1        42               12           5

  Community         5     4         2            5            6     1              4         3            1        14               \-           2
  participation                                                                                                                                  

  Employment        2     1         3            3            \-                   3         31                                     5            

  Income/benefits   10    \-        41           2            3                              2            2        5                             

  Communication     4     6         2            6            \-    \-             1         5            1        \-               2            4

  Housing           4     3         2            2            2     6              59        3            5        2                4            \-

  Socialization     3     12        3            1            \-    1              1         \-           \-       5                \-           \-

  Insurance         1     \-        \-           \-           \-    \-             \-        \-           \-       \-               \-           \-
  information                                                                                                                                    

  Legal             3     1         3            \-           33    \-             \-        8            \-       \-               \-           0

  Learn about other 10    8         10           3            17    2              2         3            \-       5                4            8
  services                                                                                                                                       

  Education         1     2         \-           \-           \-    \-             \-        3            \-       \-               8            1

  Home              1     1         \-           \-           \-    34             \-        \-           \-       \-               \-           \-
  modifications                                                                                                                                  

  Computer skills   2     \-        \-           \-           \-    \-             \-        1            \-       \-               \-           8

  Personal          3     1         1            27           \-    2              \-        \-           \-       \-               \-           \-
  assistance                                                                                                                                     

  Assistive devices 3     1         1            \-           \-    5              \-        \-           \-       \-               \-           47
  ----------------- ----- --------- ------------ ------------ ----- -------------- --------- ------------ -------- ---------------- ------------ -----------

**Table B-5. Consumer perception of life quality**

Is your life better now than it was before you went to the center? Would
you say it is...

+----------------------+--------+--------+--------+--------+--------+
| Variable             | Re     |        |        |        |        |
|                      | sponse |        |        |        |        |
|                      | (%)    |        |        |        |        |
+----------------------+--------+--------+--------+--------+--------+
|                      | Much\  | Som    | Same   | Som    | Much\  |
|                      | better | ewhat\ |        | ewhat\ | worse  |
|                      |        | better |        | worse  |        |
+----------------------+--------+--------+--------+--------+--------+
| Overall              | 47     | 29     | 19     | 3      | 2      |
+----------------------+--------+--------+--------+--------+--------+
|                      |        |        |        |        |        |
+----------------------+--------+--------+--------+--------+--------+
| Gender               |        |        |        |        |        |
+----------------------+--------+--------+--------+--------+--------+
| > Male               | 43     | 32     | 18     | 4      | 3      |
+----------------------+--------+--------+--------+--------+--------+
| > Female             | 49     | 27     | 21     | 2      | 1      |
+----------------------+--------+--------+--------+--------+--------+
| Type of Disability   |        |        |        |        |        |
+----------------------+--------+--------+--------+--------+--------+
| > Physical           | 48     | 24     | 23     | 3      | 3      |
+----------------------+--------+--------+--------+--------+--------+
| > Mental             | 48     | 36     | 13     | 2      | 0      |
+----------------------+--------+--------+--------+--------+--------+
| > Communication      | 44     | 36     | 17     | 3      | 1      |
+----------------------+--------+--------+--------+--------+--------+
| CIL Size             |        |        |        |        |        |
+----------------------+--------+--------+--------+--------+--------+
| > Small              | 49     | 29     | 16     | 3      | 3      |
+----------------------+--------+--------+--------+--------+--------+
| > Medium             | 47     | 28     | 22     | 1      | 2      |
+----------------------+--------+--------+--------+--------+--------+
| > Large              | 43     | 29     | 23     | 4      | 1      |
+----------------------+--------+--------+--------+--------+--------+
| CIL location         |        |        |        |        |        |
+----------------------+--------+--------+--------+--------+--------+
| > Rural              | 50     | 24     | 20     | 5      | 2      |
+----------------------+--------+--------+--------+--------+--------+
| > Suburban           | 47     | 20     | 25     | 6      | 1      |
+----------------------+--------+--------+--------+--------+--------+
| > Urban              | 46     | 31     | 19     | 2      | 2      |
+----------------------+--------+--------+--------+--------+--------+
| Age Group            |        |        |        |        |        |
+----------------------+--------+--------+--------+--------+--------+
| > \<18               | 60     | 18     | 10     | 7      | 4      |
+----------------------+--------+--------+--------+--------+--------+
| > 18 -- 24           | 52     | 27     | 13     | 8      | 0      |
+----------------------+--------+--------+--------+--------+--------+
| > 25 -- 44           | 49     | 28     | 20     | 2      | 1      |
+----------------------+--------+--------+--------+--------+--------+
| > 45 -- 64           | 45     | 28     | 21     | 4      | 2      |
+----------------------+--------+--------+--------+--------+--------+
| > 65+                | 36     | 39     | 22     | 0      | 3      |
+----------------------+--------+--------+--------+--------+--------+
| Race                 |        |        |        |        |        |
+----------------------+--------+--------+--------+--------+--------+
| > White              | 48     | 31     | 16     | 3      | 2      |
+----------------------+--------+--------+--------+--------+--------+
| > Non-White          | 44     | 23     | 29     | 3      | 1      |
+----------------------+--------+--------+--------+--------+--------+
| > Hispanic           | 47     | 10     | 35     | 4      | 4      |
+----------------------+--------+--------+--------+--------+--------+
| > Non-Hispanic       | 46     | 31     | 18     | 3      | 2      |
+----------------------+--------+--------+--------+--------+--------+
| Income               |        |        |        |        |        |
+----------------------+--------+--------+--------+--------+--------+
| > \<8,000            | 49     | 24     | 20     | 4      | 3      |
+----------------------+--------+--------+--------+--------+--------+
| > 8,000 -- 10,000    | 45     | 32     | 19     | 4      | 0      |
+----------------------+--------+--------+--------+--------+--------+
| > 10,001 -- 20,000   | 41     | 38     | 19     | 1      | 1      |
+----------------------+--------+--------+--------+--------+--------+
| > 20,001 -- 40,000   | 44     | 34     | 15     | 2      | 4      |
+----------------------+--------+--------+--------+--------+--------+
| > 40,001+            | 49     | 28     | 16     | 6      | 0      |
+----------------------+--------+--------+--------+--------+--------+

**Table B-6. Summary table**

  ----------------------- ----------- ----------- ------------ -----------
  Service                 \%\         \%\         \%\          \%\
                          Receiving   Very\       Gain         Change\
                          service     satisfied   knowledge\   in life
                                                  or skill     

  Information and         59          64          83           71
  referral                                                     

  Benefits advisement     41          63          80           68

  Peer support            37          62          86           76

  ADA training            29          71          87           61

  Personal assistance     29          74          68           77

  Technology/adaptive     26          73          79           74
  equipment                                                    

  Home modification       26          75          73           71

  Housing referral        26          65          77           69

  Employment advisement   20          59          65           55

  Independent living      20          69          96           82
  skills training                                              

  Transportation          19          87          72           74

  Transition from school  9           74          94           71
  to work                                                      
  ----------------------- ----------- ----------- ------------ -----------

**Table B-7. Summary table**

  --------------------- ---------- ----------- ----------- -------------- -----------
  Service               \%\        \%\         \%\         \%\            \%\
                        CILs       Consumers   Consumers   Consumers      Consumers
                        offering   receiving   very        reporting gain reporting
                        service    service     satisfied   knowledge or   change in
                                                           skill          life

  Information and       100        59          64          83             71
  referral                                                                

  Benefits advisement   89         41          63          80             68

  Peer support          92         37          62          86             76

  ADA training          93         29          71          87             61

  Personal assistance   91         29          74          68             77

  Technology/adaptive   93         26          73          79             74
  equipment                                                               

  Home modification     86         26          75          73             71

  Housing referral      98         26          65          77             69

  Employment advisement 80         20          59          65             55

  Independent living    99         20          69          96             82
  skills training                                                         

  Transportation        33         19          87          72             74

  Transition from       76         9           74          94             71
  school to work                                                          
  --------------------- ---------- ----------- ----------- -------------- -----------

**APPENDIX C**

**CONSUMER SURVEY**

**APPENDIX C**

10OMB Approval Number: 1820-0640

Expiration Date: 03/31/2004

######## 

######## Evaluation of the Centers for Independent Living Program

######### Spring 2001

ID number:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Subject's name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Subject's date of birth: \_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_

Center name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date:

Interviewer:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Final
result code: \_\_\_\_\_\_\_\_\_

INTRODUCTION

Hello. May I speak with \[Respondent\]?

RESPONDENT IS AVAILABLE 1

RESPONDENT IS NOT AVAILABLE 2  (GO TO I1)

INTRO Hello, my name is \[INTERVIEWER NAME\]. We are conducting a study
for the U.S. Department of Education's Rehabilitation Services
Administration \[about\] about Independent Living programs. We are
trying to find out what centers do, how they help people with
disabilities, and how happy center consumers are with the services they
have received.

> This survey will take about 30 minutes to complete. Your participation
> is voluntary and very important to the success of this study. Your
> answers to the questions will be kept confidential and will be used
> only for the purpose of this study.

\[GO TO VERIFICATION --V1- PAGE 2\]

I1. Is this the correct telephone number to contact \[Respondent\]?

YES 1

NO 2  (GO TO I3)

I2. Can you provide me a better time to contact \[Respondent\]? RECORD
THE RESPONSE & NOTE ON CALL RECORD.

Thank you I will call back later.

I3. Can you provide me with the correct telephone number for
\[Respondent\]?

YES 1

NO 2  Thank you for your time.

(CODE PROBLEM)

I4. What is the telephone number for \[Respondent\]? RECORD RESPONSE

> ( \|\_\_\_\|\_\_\_\|\_\_\_\| ) \|\_\_\_\|\_\_\_\|\_\_\_\| -
> \|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|
>
> (area code) (telephone number)

Thank you for the information.

Verification

S/P SUBJECT ON THE PHONE 1  (GO TO V1)

ASSISTANT ON THE PHONE 2  (GO TO AST)

PROXY ON THE PHONE 3  (GO TO PRX)

AST \[If Assistant: We would like the consumer to answer the questions
as independently as possible. We want to be sure that, wherever
possible, we are getting (consumer's name) actual opinions and
responses.\]

PRX \[(If Proxy For the remainder of the survey when I refer to "you" I
would like you to answer as though you were \[consumer's name\]. All of
the following question\[s\] pertain to him/her Please provide your best
estimate as to his/her own response or opinion.\]

V1. Your name is \[SUBJECT\], is that correct?

YES -- EXACT MATCH 1  (GO TO V2)

YES -- MATCH WITH EXPLANATION 2

NO 3  (RETURN TO RESP. NOT

AVAILABLE)

> V1EXPLAIN

V2. We have your date of birth as \[MM/DD/YYYY\], is that correct?

YES 1  (GO TO V3)

NO 2

V2UPDATE What is your correct date of birth?

> \_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_\_\_

MM DD YYYY

V3. Are you currently or have you ever accepted any services from a
Center for Independent Living?

> \[IF NEEDED: We show you may have received services from \[CENTER
> NAME\].\]

YES 1

NO 2  Thank you, we will check

with the center and may be

calling you again in the next

few days.

(CODE PROBLEM)

V4. Did the center contact you and ask you if you wanted to participate
in this survey?

YES 1

NO 2

V5. \[IF NECESSARY ASK: Are you ...\]

Male 1

Female 2

The first set of questions asks about the timeframe during which you
received services.

1a. When did you first contact the center for services?

\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_\_\_

MM DD YYYY

b\. Are you still receiving services from the center?

YES 1  GO TO Q.2

NO 2

REFUSED -7  (GO TO 2)

DON'T KNOW -8 

c\. How long has it been since you received services from the center?
Would you say...

Less than three months, 1

Three to six months, 2

Seven months to one year, or 3

More than one year? 4

REFUSED -7

DON'T KNOW -8

d\. Why are you no longer receiving services from the center? Would you
say it's because...

You already met your goal, 1

There was nothing more the center could

do for you, 2

You were dissatisfied with services, or 3

Some other reason? 91

(SPECIFY)

REFUSED -7

DON'T KNOW -8

e\. Are you still involved with the center as a volunteer or on some
advocacy issue?

YES 1

NO 2 

REFUSED -7  GO TO Q.1g

DON'T KNOW -8 

f\. Is that involvement as a volunteer, activist, or in some other way?

VOLUNTEER 1

ACTIVIST 2

IN SOME OTHER WAY 3

(SPECIFY)

REFUSED -7

DON'T KNOW -8

> g\. Would you go back to the center if you needed additional services
> or if you decided to work on an advocacy issue?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

2.  Have you ever received services from an IL \[Independent Living\]
    center other than the one that asked you to participate in this
    survey?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

This next set of questions asks about getting to and using center
services and programs.

3a. Have you ever visited the center for independent living?

YES 1

NO 2  GO TO Q.4h

REFUSED -7  (GO TO 4h)

DON'T KNOW -8 

b\. Did you visit the main center office or a satellite or branch
office?

MAIN 1

SATELLITE 2

REFUSED -7

DON'T KNOW -8

c\. How \[do/did\] you usually get to the center?

> I DRIVE 1
>
> I GET A RIDE FROM SOMEONE 2
>
> I TAKE REGULAR ROUTE TRANSIT 3
>
> I TAKE A DOOR-TO-DOOR
>
> TRANSPORTATION SERVICE 4
>
> I WALK 5
>
> I TAKE TRANSPORTATION PROVIDED
>
> BY THE CENTER 6
>
> OTHER? 91
>
> (SPECIFY)

REFUSED -7

DON'T KNOW -8

4\. How would you rate the following statements about the center you
\[use/used\]? Please tell me whether you strongly disagree, somewhat
disagree, neither disagree nor agree, somewhat agree, or strongly agree
with each statement.

+------------------------+------+------+------+------+------+---+---+---+
|                        | ##   | ##   | #    | ##   | ##   | * | * | * |
|                        | #### | #### | #### | #### | #### | * | * | * |
|                        | ###  | ###  | #### | ###  | ###  | R | D | N |
|                        |      |      |  NEI |      |      | F | K | A |
|                        | ###  | ###  | THER | #### | #### | * | * | * |
|                        | #### | #### |      | #### | #### | * | * | * |
|                        | ## S | ## S | #### | # SO | # ST |   |   |   |
|                        | TRON | OMEW | #### | MEWH | RONG |   |   |   |
|                        | GLY  | HAT  | # DI | AT A | LY A |   |   |   |
|                        | DISA | DISA | SAGR | GREE | GREE |   |   |   |
|                        | GREE | GREE | EE N |      |      |   |   |   |
|                        |      |      | OR A |      |      |   |   |   |
|                        |      |      | GREE |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| a\. I was easily able  | 1    | 2    | 3    | 4    | 5    | - | - | - |
| to enter or leave the  |      |      |      |      |      | 7 | 8 | 9 |
| building and could     |      |      |      |      |      |   |   |   |
| easily use any         |      |      |      |      |      |   |   |   |
| telephone security     |      |      |      |      |      |   |   |   |
| system that might      |      |      |      |      |      |   |   |   |
| exist.                 |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| b\. I could physically | 1    | 2    | 3    | 4    | 5    | - | - | - |
| move around individual |      |      |      |      |      | 7 | 8 | 9 |
| offices easily once    |      |      |      |      |      |   |   |   |
| inside the center.     |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| c\. Accessible parking | 1    | 2    | 3    | 4    | 5    | - | - | - |
| was located close to   |      |      |      |      |      | 7 | 8 | 9 |
| the entrance I used.   |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| d\. The center was     | 1    | 2    | 3    | 4    | 5    | - | - | - |
| accessible using       |      |      |      |      |      | 7 | 8 | 9 |
| regular route or       |      |      |      |      |      |   |   |   |
| door-to-door           |      |      |      |      |      |   |   |   |
| transportation.        |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| e\. Center services    | 1    | 2    | 3    | 4    | 5    | - | - | - |
| and programs were      |      |      |      |      |      | 7 | 8 | 9 |
| scheduled at           |      |      |      |      |      |   |   |   |
| convenient times, so I |      |      |      |      |      |   |   |   |
| did not have to miss   |      |      |      |      |      |   |   |   |
| work or school         |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| f\. I was usually able | 1    | 2    | 3    | 4    | 5    | - | - | - |
| to see the center      |      |      |      |      |      | 7 | 8 | 9 |
| staff person within 15 |      |      |      |      |      |   |   |   |
| minutes of my          |      |      |      |      |      |   |   |   |
| scheduled appointment. |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| g\. The center offered | 1    | 2    | 3    | 4    | 5    | - | - | - |
| me the opportunity to  |      |      |      |      |      | 7 | 8 | 9 |
| register to vote       |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| h\. I could contact    | 1    | 2    | 3    | 4    | 5    | - | - | - |
| the center easily by   |      |      |      |      |      | 7 | 8 | 9 |
| telephone on my first  |      |      |      |      |      |   |   |   |
| attempt                |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| i\. The telephone      | 1    | 2    | 3    | 4    | 5    | - | - | - |
| voice mail system (if  |      |      |      |      |      | 7 | 8 | 9 |
| any) was easy to use   |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| j\. If I needed to     | 1    | 2    | 3    | 4    | 5    | - | - | - |
| leave a message for    |      |      |      |      |      | 7 | 8 | 9 |
| someone, I was called  |      |      |      |      |      |   |   |   |
| back by the next day   |      |      |      |      |      |   |   |   |
| the center was open    |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| k\. I did not have to  | 1    | 2    | 3    | 4    | 5    | - | - | - |
| visit the center,      |      |      |      |      |      | 7 | 8 | 9 |
| because they helped    |      |      |      |      |      |   |   |   |
| with the problem over  |      |      |      |      |      |   |   |   |
| the phone.             |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| l\. I was able to get  | 1    | 2    | 3    | 4    | 5    | - | - | - |
| center services as     |      |      |      |      |      | 7 | 8 | 9 |
| soon as I needed them. |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| m\. I could read and   | 1    | 2    | 3    | 4    | 5    | - | - | - |
| understand all written |      |      |      |      |      | 7 | 8 | 9 |
| material the Center    |      |      |      |      |      |   |   |   |
| gave to me.            |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| n\. I got an           | 1    | 2    | 3    | 4    | 5    | - | - | - |
| appointment with       |      |      |      |      |      | 7 | 8 | 9 |
| someone at the center  |      |      |      |      |      |   |   |   |
| within the period of   |      |      |      |      |      |   |   |   |
| time I wanted.         |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+
| o\. The amount of      | 1    | 2    | 3    | 4    | 5    | - | - | - |
| paperwork I had to     |      |      |      |      |      | 7 | 8 | 9 |
| complete to get        |      |      |      |      |      |   |   |   |
| services from the      |      |      |      |      |      |   |   |   |
| center was             |      |      |      |      |      |   |   |   |
| appropriate.           |      |      |      |      |      |   |   |   |
+------------------------+------+------+------+------+------+---+---+---+

Now, I will ask you some questions about written and oral communications
with the center:

5a. Do you need printed materials in alternative format such as Braille,
large print or cassette tape?

YES 1

NO 2 

REFUSED -7  GO TO Q.6a

DON'T KNOW -8 

b\. \[Do/Did\] you receive written materials in the format you need from
the center?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

6a. Do you need a sign language interpreter or CART reporter to
communicate?

ALWAYS 1

SOMETIMES 2

NEVER 3 

REFUSED -7  GO TO BOX 1

DON'T KNOW -8 

> b\. Was there a sign language interpreter or CART reporter available
> at your center appointments or other center activities you attended?
> Would you say . . .

Always 1

Sometimes, or 2

Never? 3

REFUSED -7

DON'T KNOW -8

**BOX 1**

**INTERVIEWER NOTE: IF Q3a = 2, -7, -8, CHECK THIS BOX ...... AND GO TO
Q.9.**

7a. How often did you have face-to-face contact with someone from the
Center during the last year? Would you say...

Once per week or more, 1

Two to three times per month, 2

Once per month, 3

Once every three months, 4

Once or twice per year, or 5

Not at all? 6 

REFUSED -7  GO TO Q.9

DON'T KNOW -8 

> b\. Did you need an appointment to receive center services or were you
> able to just "walk in?"

NEEDED AN APPOINTMENT 1

WALK-IN 2

DEPENDED UPON SERVICE 3

REFUSED -7

DON'T KNOW -8

8a. Did you request a phone call to remind you about your appointments
with the center?

YES 1

NO 2 

REFUSED -7  GO TO Q.9

DON'T KNOW -8 

b\. Did the center call you?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

9\. Did the center tell you how to file a complaint with the Client
Assistance Program if you were unhappy with any of the center's
services?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

Now, please think back to when you first contacted the center.

10\. In which of the following areas of life did you have a problem you
wanted to solve or a goal you wanted to achieve?

+---------------------------------------+-----+-----+-----+-----+-----+
|                                       | *   | **N | **R | **D | **N |
|                                       | *YE | O** | F** | K** | A** |
|                                       | S** |     |     |     |     |
+---------------------------------------+-----+-----+-----+-----+-----+
| a\. Community integration - amount of | 1   | 2   | -7  | -8  | -9  |
| time you spend participating in your  |     |     |     |     |     |
| community                             |     |     |     |     |     |
+---------------------------------------+-----+-----+-----+-----+-----+
| b\. Self-esteem                       | 1   | 2   | -7  | -8  | -9  |
+---------------------------------------+-----+-----+-----+-----+-----+
| c\. Employment                        | 1   | 2   | -7  | -8  | -9  |
+---------------------------------------+-----+-----+-----+-----+-----+
| d\. Education level                   | 1   | 2   | -7  | -8  | -9  |
+---------------------------------------+-----+-----+-----+-----+-----+
| e\. Knowledge of disability rights    | 1   | 2   | -7  | -8  | -9  |
| laws                                  |     |     |     |     |     |
+---------------------------------------+-----+-----+-----+-----+-----+
| f\. Housing                           | 1   | 2   | -7  | -8  | -9  |
+---------------------------------------+-----+-----+-----+-----+-----+
| g\. Personal assistance services      | 1   | 2   | -7  | -8  | -9  |
+---------------------------------------+-----+-----+-----+-----+-----+
| h\. Ability to get around in your     | 1   | 2   | -7  | -8  | -9  |
| community                             |     |     |     |     |     |
+---------------------------------------+-----+-----+-----+-----+-----+
| i\. Knowledge of disability services  | 1   | 2   | -7  | -8  | -9  |
+---------------------------------------+-----+-----+-----+-----+-----+
| j\. Entertainment or recreational     | 1   | 2   | -7  | -8  | -9  |
| activities                            |     |     |     |     |     |
+---------------------------------------+-----+-----+-----+-----+-----+
| k\. Income                            | 1   | 2   | -7  | -8  | -9  |
+---------------------------------------+-----+-----+-----+-----+-----+
| l\. Increased level or number of      | 1   | 2   | -7  | -8  | -9  |
| benefits                              |     |     |     |     |     |
+---------------------------------------+-----+-----+-----+-----+-----+
| m.  Some other area?                  | 1   | 2   | -7  | -8  | -9  |
|                                       |     |     |     |     |     |
| (SPECIFY)                             |     |     |     |     |     |
+---------------------------------------+-----+-----+-----+-----+-----+

11\. Did the center give you information about different options that
would help you reach your IL goal?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

12\. Who decided on the services that you would get in order to reach
your goal?

I DID 1

THE IL STAFF PERSON 2

I DECIDED ALONG WITH AN IL STAFF

PERSON 3

A FRIEND OR FAMILY MEMBER 4

OTHER? 91

(SPECIFY)

REFUSED -7

DON'T KNOW -8

13a. Did you achieve your goal or solve the problem? Would you say . . .

Yes, 1  GO TO Q.14INTRO

Partially, or 2 

No 3  GO TO Q.13b

REFUSED -7  GO TO Q.14INTRO

DON'T KNOW -8 

b\. Why have you not achieved your goal or solved the problem?

STILL WORKING ON IT 1

CHANGED MY MIND 2

OTHER? 91

(SPECIFY)

REFUSED -7

DON'T KNOW -8

> 14INTRO. I'm going to read you a list of services that centers
> provide. Please tell me whether or not you received each service.
>
> INTERVIEWER: FOR EACH SERVICE RECEIVED, ASK THE FOLLOW-UP QUESTIONS
> BEFORE PROCEEDING TO NEXT SERVICE.
>
> Please tell me whether you were very dissatisfied, somewhat
> dissatisfied, neither dissatisfied nor satisfied, somewhat satisfied,
> or very satisfied with the service you received.
>
> Do you think that you gained knowledge or a skill as a result of this
> service?
>
> Did you make any changes in your life as a result of this service?.
>
> IF CHANGES WERE MADE, ASK: What change did you make?

<table style="width:100%;">
<colgroup>
<col style="width: 17%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="3"><strong>COL. A</strong></td>
<td colspan="5"><strong>IF YES IN COL. A:</strong></td>
<td colspan="3"><strong>COL. C</strong></td>
<td colspan="3"><strong>COL. D</strong></td>
<td><strong>IF YES IN COL. D.:</strong></td>
</tr>
<tr class="even">
<td><strong>SERVICE</strong></td>
<td colspan="3"><p><strong>RECEIVED?</strong></p>
<p><strong>YES NO</strong></p></td>
<td><strong>VERY DISSATISFIED</strong></td>
<td><strong>SOMEWHAT DISSATISFIED</strong></td>
<td><strong>NEITHER DISSATISFIED NOR SATISFIED</strong></td>
<td><strong>SOMEWHAT SATISFIED</strong></td>
<td><strong>VERY SATISFIED</strong></td>
<td colspan="3"><p><strong>GAINED KNOWLEDGE OR SKILL?</strong></p>
<p><strong>YES NO</strong></p></td>
<td colspan="3"><p><strong>CHANGED IN LIFE?</strong></p>
<p><strong>YES NO</strong></p></td>
<td><strong>WHAT CHANGE?</strong></td>
</tr>
<tr class="odd">
<td>14. Information and referral, where a staff person gives you the
name and phone number of another agency, or tells you where you can get
a particular service</td>
<td colspan="2">1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td colspan="2">1</td>
<td>2</td>
<td colspan="2">1</td>
<td>2</td>
<td></td>
</tr>
<tr class="even">
<td>15. Peer support, where you meet with one person or a group of
people who have disabilities to talk about and solve problems</td>
<td colspan="2">1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td colspan="2">1</td>
<td>2</td>
<td colspan="2">1</td>
<td>2</td>
<td></td>
</tr>
<tr class="odd">
<td>16. Benefits advisement, where someone tells you about SSI, SSDI,
Medicaid, food stamps, or other benefits</td>
<td colspan="2">1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td colspan="2">1</td>
<td>2</td>
<td colspan="2">1</td>
<td>2</td>
<td></td>
</tr>
<tr class="even">
<td>17. Independent living skills training, where you learn how to
manage a budget, shop for food, or do other things necessary to live
independently</td>
<td>1</td>
<td colspan="2">2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td colspan="2">2</td>
<td>1</td>
<td colspan="2">2</td>
<td></td>
</tr>
</tbody>
</table>

continued:

<table style="width:100%;">
<colgroup>
<col style="width: 17%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="3"><strong>COL. A</strong></td>
<td colspan="5"><strong>IF YES IN COL. A:</strong></td>
<td colspan="2"><strong>COL. C</strong></td>
<td colspan="2"><strong>COL. D</strong></td>
<td><strong>IF YES IN COL. D.:</strong></td>
</tr>
<tr class="even">
<td><strong>SERVICE</strong></td>
<td colspan="3"><p><strong>RECEIVED?</strong></p>
<p><strong>YES NO</strong></p></td>
<td><strong>VERY DISSATISFIED</strong></td>
<td><strong>SOMEWHAT DISSATISFIED</strong></td>
<td><strong>NEITHER DISSATISFIED NOR SATISFIED</strong></td>
<td><strong>SOMEWHAT SATISFIED</strong></td>
<td><strong>VERY SATISFIED</strong></td>
<td colspan="2"><p><strong>GAINED KNOWLEDGE OR SKILL?</strong></p>
<p><strong>YES NO</strong></p></td>
<td colspan="2"><p><strong>CHANGED IN LIFE?</strong></p>
<p><strong>YES NO</strong></p></td>
<td><strong>WHAT CHANGE?</strong></td>
</tr>
<tr class="odd">
<td>18. Housing referral or assistance, where someone helps you look for
a place to live</td>
<td colspan="2">1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td></td>
</tr>
<tr class="even">
<td>19. Personal assistance services or referral, where someone helps
you learn how to use a personal assistant or refers you to someone who
can be a personal assistant</td>
<td colspan="2">1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td></td>
</tr>
<tr class="odd">
<td>20. Help with modifications at home, where someone helps to make
your home more accessible to you</td>
<td colspan="2">1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td></td>
</tr>
<tr class="even">
<td><p>21. Employment advisement, training, or</p>
<p>referral, where someone helps you look for a job or with problems you
are having on the job</p></td>
<td colspan="2">1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td></td>
</tr>
<tr class="odd">
<td>22. Transition from school to work or independent living, where
someone helps you plan for work or living independently when you leave
school</td>
<td colspan="2">1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td></td>
</tr>
<tr class="even">
<td>23. Getting technology or adaptive equipment, like wheelchairs,
adapted computers, or hearing aids</td>
<td>1</td>
<td colspan="2">2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td></td>
</tr>
</tbody>
</table>

continued:

<table style="width:100%;">
<colgroup>
<col style="width: 17%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="2"><strong>COL. A</strong></td>
<td colspan="5"><strong>IF YES IN COL. A:</strong></td>
<td colspan="2"><strong>COL. C</strong></td>
<td colspan="2"><strong>COL. D</strong></td>
<td><strong>IF YES IN COL. D.:</strong></td>
</tr>
<tr class="even">
<td><strong>SERVICE</strong></td>
<td colspan="2"><p><strong>RECEIVED?</strong></p>
<p><strong>YES NO</strong></p></td>
<td><strong>VERY DISSATISFIED</strong></td>
<td><strong>SOMEWHAT DISSATISFIED</strong></td>
<td><strong>NEITHER DISSATISFIED NOR SATISFIED</strong></td>
<td><strong>SOMEWHAT SATISFIED</strong></td>
<td><strong>VERY SATISFIED</strong></td>
<td colspan="2"><p><strong>GAINED KNOWLEDGE OR SKILL?</strong></p>
<p><strong>YES NO</strong></p></td>
<td colspan="2"><p><strong>CHANGED IN LIFE?</strong></p>
<p><strong>YES NO</strong></p></td>
<td><strong>WHAT CHANGE?</strong></td>
</tr>
<tr class="odd">
<td>24. Transportation, where the center picks you up and takes you to
an appointment or an activity that is not sponsored by the center,
arranges transportation for you, or helps you pay for
transportation</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td></td>
</tr>
<tr class="even">
<td>25. ADA training, where the center teaches you about your rights
under the Americans with Disabilities Act</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td></td>
</tr>
<tr class="odd">
<td><p>26. Any other services?</p>
<p>(SPECIFY)</p></td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>1</td>
<td>2</td>
<td>1</td>
<td>2</td>
<td></td>
</tr>
</tbody>
</table>

27a. Have you ever had difficulty receiving services from or gaining
access to an agency other than the center because of your disability?

YES 1

NO 2 

REFUSED -7  GO TO Q.28

DON'T KNOW -8 

b\. Did the problem get solved? Would you say . . .

The problem was solved, 1

The problem was partially solved, or 2 

The problem was not solved? 3  GO TO Q.28

REFUSED -7 

DON'T KNOW -8 

> c\. Did the center help you solve the problem?

YES 1

NO 2 

REFUSED -7  GO TO Q.28

DON'T KNOW -8 

d\. Which statement most closely matches what happened? Would you say .
. .

The center staff solved it for me, 1

Center staff told me how to solve it myself, 2

The staff worked with me to solve the

problem, or 3

Staff put me in touch with other people with

disabilities and we solved it together? 4

REFUSED -7

DON'T KNOW -8

> e\. The next time this or a similar situation comes up, how would you
> handle it? Will\
> you . . .

Contact the center and let them solve the

problem, 1

Solve the problem yourself, 2

Work with center staff to solve the

problem, or 3

Get in touch with other people with

disabilities to solve the problem together? 4

REFUSED -7

DON'T KNOW -8

The next questions focus on your experiences working with center staff.
First, we want to know how the center staff treated you as an
individual.

28\. How well did the IL staff person you worked with the most
understand your disability? Would you say\...

Very well, 1

Somewhat, 2

Poorly, or 3

Not at all? 4

REFUSED -7

DON'T KNOW -8

29\. How sensitive to your cultural or ethnic customs was the IL staff
you worked with the most? Would you say . . .

Very sensitive, 1

Somewhat sensitive, 2

Somewhat insensitive, 3

Very insensitive, or 4

My culture was not relevant? 5

REFUSED -7

DON'T KNOW -8

30\. Did the IL staff you saw most often communicate with you in your
preferred language?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

31\. Did the IL staff person you saw most often listen to your
individual ideas and suggestions? Would you say . . .

Always, 1

Sometimes, 2

Rarely, or 3

Never? 4

REFUSED -7

DON'T KNOW -8

32a. Would you have liked the IL staff to have done something
differently?

YES 1

NO 2  GO TO Q.33

REFUSED -7

DON'T KNOW -8

b\. What would it be?

33\. Did the center tell you about the Independent Living movement, or
about it's philosophy on IL?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

34\. Did the center staff tell you about groups of people with
disabilities with whom you could share problems, sometimes known as peer
support groups?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

35\. Did the center staff encourage you to advocate for yourself?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

36\. Did the center provide you with training or information about
federal, state, or local advocacy issues, while you were involved in the
center?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

37\. Did you get involved in advocacy issues to change systems or
programs for people with disabilities?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

38\. Overall, did the center staff help you to develop a positive view
of yourself? Would you say . . .

Yes, 1

No, or 2

I already had a positive view of myself? 3

REFUSED -7

DON'T KNOW -8

39\. Overall, how satisfied were you with the IL staff efforts to help
you work toward your goal? Would you say . . .

Very satisfied, 1

Somewhat satisfied, 2

Neither satisfied nor dissatisfied, 3

Somewhat dissatisfied, or 4

Very dissatisfied? 5

REFUSED -7

DON'T KNOW -8

40\. If you thought the center should be doing something differently,
would you do any of the following? How about\.... . .

> YES NO RF DK
>
> Talk to a center staff person? 1 2 -7 -8
>
> Talk to the executive director? 1 2 -7 -8
>
> Talk to a board member? 1 2 -7 -8
>
> Talk to a friend? 1 2 -7 -8
>
> Talk to an advocacy organization? 1 2 -7 -8
>
> Something else? 1 2 -7 -8
>
> (SPECIFY)

41\. Overall, how satisfied were you with your experience at the center?
Would you say . . .

Very satisfied, 1

Somewhat satisfied, 2

Neither satisfied nor dissatisfied, 3

Somewhat dissatisfied, or 4

Very dissatisfied? 5

REFUSED -7

DON'T KNOW -8

42\. Overall, how helpful would you say the center has been in achieving
your independent living goals? Would you say . . .

Very helpful, 1

Somewhat helpful, 2

Neither helpful nor unhelpful, 3

Somewhat unhelpful, or 4

Not at all helpful? 5

REFUSED -7

DON'T KNOW -8

43\. Is your life better now than it was before you went to the center?
Would you say it is . . .

Much better, 1

Somewhat better, 2

The same, 3

Somewhat worse, or 4

Much worse? 5

REFUSED -7

DON'T KNOW -8

44\. Now, I will read you a list of areas of life. Please tell me
whether each life area has not improved at all, has improved somewhat,
or has improved a great deal as a result of your contact with the
center.

+------------------------------+-------+-------+--------+---+---+---+---+---+
|                              | ####  |       |        |   |   |   |   |   |
|                              | ##### |       |        |   |   |   |   |   |
|                              |  RATE |       |        |   |   |   |   |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
|                              | **NOT | **IMP | **HAS  | * | * |   | * |   |
|                              | IMP   | ROVED | IM     | * | * |   | * |   |
|                              | ROVED | SOMEW | PROVED | R | D |   | N |   |
|                              | AT    | HAT** | A      | F | K |   | A |   |
|                              | ALL** |       | GREAT  | * | * |   | * |   |
|                              |       |       | DEAL** | * | * |   | * |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| a\. Community integration -  | 1     | 2     | 3      | - | - |   | - |   |
| amount of time you spend     |       |       |        | 7 | 8 |   | 9 |   |
| participating in your        |       |       |        |   |   |   |   |   |
| community                    |       |       |        |   |   |   |   |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| b\. Self-esteem              | 1     | 2     | 3      | - | - |   | - |   |
|                              |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| c\. Employment               | 1     | 2     | 3      | - | - |   | - |   |
|                              |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| d\. Education level          | 1     | 2     | 3      | - | - |   | - |   |
|                              |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| e\. Knowledge of disability  | 1     | 2     | 3      | - | - |   | - |   |
| rights laws                  |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| f\. Housing                  | 1     | 2     | 3      | - | - |   | - |   |
|                              |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| g\. Personal assistance      | 1     | 2     | 3      | - | - |   | - |   |
| services                     |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| h\. Ability to get around in | 1     | 2     | 3      | - | - |   | - |   |
| your community               |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| i\. Knowledge of disability  | 1     | 2     | 3      | - | - |   | - |   |
| services                     |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| j\. Entertainment or         | 1     | 2     | 3      | - | - |   | - |   |
| recreational activities      |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| k\. Income                   | 1     | 2     | 3      | - | - |   | - |   |
|                              |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| l\. Increased level or       | 1     | 2     | 3      | - | - |   | - |   |
| number of benefits           |       |       |        | 7 | 8 |   | 9 |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+
| m.  Some other area?         | 1     | 2     | 3      | - | - |   | - |   |
|                              |       |       |        | 7 | 8 |   | 9 |   |
| (SP                          |       |       |        |   |   |   |   |   |
| ECIFY)\_\_\_\_\_\_\_\_\_\_\_ |       |       |        |   |   |   |   |   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ |       |       |        |   |   |   |   |   |
+------------------------------+-------+-------+--------+---+---+---+---+---+

45a. Would you refer a friend to the IL center if they needed similar
services or had a similar problem?

YES 1

NO 2 

REFUSED -7  GO TO Q.46

DON'T KNOW -8 

b\. Have you ever done so?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

46\. Do you do any volunteer work for the center, for example, serving
on the board, an advisory committee, working in the center's advocacy
organization or answering the telephone?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

47 INTRO. Now, I am going to ask you some questions about other services
that you may have received, services you may need, and how you feel
about certain aspects of your life. These questions are
[not]{.underline} related to centers for independent living. I am asking
these questions so that we know what other services center consumers
need, and so that we can compare people who get center services with
those who do not receive services from a center. All of your answers
will be kept strictly confidential and we will not attach your name to
any answers you give. \[If you feel uncomfortable answering these
questions, we can skip the ones you don't want to answer or we can stop
at any time.\]

47a. (NHIS-D) Vocational rehabilitation provides equipment and services
to people to improve their ability to work. Have you ever received any
equipment or services through a vocational rehabilitation agency?

YES 1

NO 2 

REFUSED -7  GO TO Q.48a

DON'T KNOW -8 

b\. How satisfied were you with the services you received? Would you say
. . .

Very satisfied, 1

Somewhat satisfied, 2

Neither satisfied nor dissatisfied, 3

Somewhat dissatisfied, or 4

Very dissatisfied? 5

REFUSED -7

DON'T KNOW -8

48\. (NHIS-D) Do you have any difficulty doing the following? How
about....

> YES NO RF DK

a\. Entering or leaving your home? 1 2 -7 -8

b\. Opening or closing any of the doors in

your home? 1 2 -7 -8

c\. Reaching or opening cabinets in your

home? 1 2 -7 -8

d\. Using the bathroom in your home? 1 2 -7 -8

49. (NHIS-D) Some residences have special features to assist persons who
    have disabilities. Whether you use them or not, please tell us if
    your residence has any of these features and whether you need any of
    them. How about...

+----------------------------+----+----+----+----+----+----+----+----+
| **FEATURE**                | *  |    |    |    | ** |    |    |    |
|                            | *H |    |    |    | NE |    |    |    |
|                            | AS |    |    |    | ED |    |    |    |
|                            | FE |    |    |    | FE |    |    |    |
|                            | AT |    |    |    | AT |    |    |    |
|                            | UR |    |    |    | UR |    |    |    |
|                            | E? |    |    |    | E? |    |    |    |
|                            | ** |    |    |    | ** |    |    |    |
|                            |    |    |    |    |    |    |    |    |
|                            | *  |    |    |    | *  |    |    |    |
|                            | *Y |    |    |    | *Y |    |    |    |
|                            | ES |    |    |    | ES |    |    |    |
|                            | NO |    |    |    | NO |    |    |    |
|                            | R  |    |    |    | R  |    |    |    |
|                            | EF |    |    |    | EF |    |    |    |
|                            | DK |    |    |    | DK |    |    |    |
|                            | ** |    |    |    | ** |    |    |    |
+----------------------------+----+----+----+----+----+----+----+----+
| a\. Widened doorways or    | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
| hallways?                  |    |    |    |    |    |    |    |    |
+----------------------------+----+----+----+----+----+----+----+----+
| b\. Ramps or street level  | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
| entrances?                 |    |    |    |    |    |    |    |    |
+----------------------------+----+----+----+----+----+----+----+----+
| c\. Railings?              | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
+----------------------------+----+----+----+----+----+----+----+----+
| d\. Automatic or           | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
| easy-to-open doors?        |    |    |    |    |    |    |    |    |
+----------------------------+----+----+----+----+----+----+----+----+
| e\. Accessible parking or  | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
| drop-off site?             |    |    |    |    |    |    |    |    |
+----------------------------+----+----+----+----+----+----+----+----+
| f\. Bathroom               | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
| modifications?             |    |    |    |    |    |    |    |    |
+----------------------------+----+----+----+----+----+----+----+----+
| g\. Kitchen modifications? | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
+----------------------------+----+----+----+----+----+----+----+----+
| h\. Elevator, chair lift,  | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
| or stair glide?            |    |    |    |    |    |    |    |    |
+----------------------------+----+----+----+----+----+----+----+----+
| i\. Alerting devices?      | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
+----------------------------+----+----+----+----+----+----+----+----+
| j\. Any other special      | 1  | 2  | -7 | -8 | 1  | 2  | -7 | -8 |
| features?                  |    |    |    |    |    |    |    |    |
|                            |    |    |    |    |    |    |    |    |
| (SPECIFY)                  |    |    |    |    |    |    |    |    |
+----------------------------+----+----+----+----+----+----+----+----+

50a. (NHIS-D) Some communities have special bus, cab or van services for
people who have difficulty using the regular public transportation
service. When using this special service, people can call ahead and ask
to be picked up. Is such a service available in your area?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

b\. Have you used this special service in the past 12 months?

YES 1  GO TO Q.51a

NO 2

REFUSED -7

DON'T KNOW -8

c\. Why haven\'t you used this service in the past 12 months?

> YES NO RF DK

1\. You don\'t know how to use the service? 1 2 -7 -8

> 2\. You need help from another person? 1 2 -7 -8
>
> 3\. You can\'t use the service alone? 1 2 -7 -8
>
> 4\. You can\'t use a telephone? 1 2 -7 -8
>
> 5\. You don\'t have a telephone? 1 2 -7 -8
>
> 6\. You can\'t read? 1 2 -7 -8
>
> 7\. Because of Illness? 1 2 -7 -8
>
> 8\. You can\'t get reservation for service? 1 2 -7 -8
>
> 9\. Hours of service are inadequate? 1 2 -7 -8
>
> 10\. Pickup is unreliable or inconvenient? 1 2 -7 -8
>
> 11\. Because of the cost? 1 2 -7 -8
>
> 12\. You were denied use of the service? 1 2 -7 -8
>
> 13\. The service is not needed or wanted? 1 2 -7 -8
>
> 14\. Some other reason? 1 2 -7 -8
>
> (SPECIFY)

51a. (NHIS-D) During the past 12 months, have you used local public
transportation, such as a regular bus line, rapid transit, subway, or
street car?

YES 1

NO 2 

NO PUBLIC SYSTEM AVAILABLE 3  GO TO Q.52

REFUSED -7 

DON'T KNOW -8 

> b\. Does an impairment or health problem limit your use of the public
> transportation service?

YES 1

NO 2

REFUSED -7

DON'T KNOW -8

> c\. During the past 12 months, how often did you use the local public
> transportation service? Would you say . . .

Everyday or almost everyday, 1

Occasionally, or 2

Seldom? 3

REFUSED -7

DON'T KNOW -8

52\. Regarding your present social activities, do you feel that you are
doing about enough, too much, or would you like to be doing more?

ABOUT ENOUGH 1

TOO MUCH 2

WOULD LIKE TO BE DOING MORE 3

REFUSED -7

DON'T KNOW -8

53a. Has your household been without telephone service at any time
during the past twelve months?

YES 1

NO 2 

REFUSED -7  GO TO Q.54

DON'T KNOW -8 

b\. For how long was your household without telephone service in the
past 12 months?

ENTIRE 12 MONTHS 1

NUMBER OF DAYS, WEEKS, MONTHS \|\_\_\_\|\_\_\_\|\_\_\_\|  DAYS

 WEEKS

 MONTHS

REFUSED -7

DON'T KNOW -8

Now I'm going to ask some questions that might describe your attitudes
and feelings.

54\. In general, how satisfied are you with the way your life is going
these days? Would you say . . .

Very satisfied, 1

Somewhat satisfied, or 2

Not satisfied? 3

REFUSED -7

DON'T KNOW -8

55\. Day to day, how much choice do you have about what you do and when
you do it? Would you say you have . . .

> A great deal of choice, 1
>
> Some choice, or 2
>
> No choice? 3
>
> REFUSED -7
>
> DON'T KNOW -8

56\. How confident are you in your ability to deal with daily living?
Would you say you feel . . .

> Very confident, 1
>
> Somewhat confident, or 2
>
> Not confident? 3
>
> REFUSED -7
>
> DON'T KNOW -8

57\. How much do you worry about not knowing who to turn to for help?
Would you say you worry . . .

> A lot, 1
>
> Some, or 2
>
> Not at all? 3
>
> REFUSED -7
>
> DON'T KNOW -8

Now, in our final section, we just need to know a little bit more about
you.

58a. Please tell me which of the following disabilities you have.

> YES NO RF DK

1\. Visual impairment? 1 2 -7 -8

2\. Hearing impairment? 1 2 -7 -8

3\. Orthopedic, including amputations? 1 2 -7 -8

4\. Non-orthopedic, physical? 1 2 -7 -8

5\. Mental illness/Psychiatric disability? 1 2 -7 -8

6\. Mental retardation? 1 2 -7 -8

7\. Substance abuse? 1 2 -7 -8

8\. Learning disability? 1 2 -7 -8

9\. Traumatic brain injury? 1 2 -7 -8

10\. Environmental illness? 1 2 -7 -8

11\. Something else? 1 2 -7 -8

(SPECIFY)

> b\. Please tell me which category most closely describes your primary
> disability. Would you say your [primary disability]{.underline} is
> related to:
>
> a physical impairment 1
>
> a visual impairment 2
>
> a hearing impairment 3
>
> a cognitive impairment 4
>
> a mental health or substance abuse problem 5
>
> a speech impairment, or 6
>
> something else? 7
>
> (SPECIFY)
>
> REFUSED -7
>
> DON'T KNOW -8

59\. Now, I'd like to ask you some questions about your disability and
the type of assistance you need. Please tell me whether you can do each
of the following activities by yourself, if you can do them with
assistance from technology or another person, or whether you can not do
them at all.

  -------------------------- -------------- ---------------- ------------ -------- --------
  **ITEM**                   **WITHOUT      **WITH           **CAN NOT DO **RF**   **DK**
                             ASSISTANCE**   ASSISTANCE FROM  ACTIVITY**            
                                            TECHNOLOGY/                            
                                            EQUIPMENT OR                           
                                            FROM ANOTHER                           
                                            PERSON**                               

  Walking for a quarter of a 1              2                4            -7       -8
  mile - about three city                                                          
  blocks?                                                                          

  Walking up a flight of     1              2                4            -7       -8
  stairs without resting?                                                          

  Doing heavy housework      1              2                4            -7       -8
  (such as scrubbing floors,                                                       
  or washing windows)?                                                             

  Getting around outside the 1              2                4            -7       -8
  house?                                                                           

  Reading and understanding  1              2                4            -7       -8
  the newspaper?                                                                   

  Writing?                   1              2                4            -7       -8

  Using the telephone?       1              2                4            -7       -8

  Managing your money (such  1              2                4            -7       -8
  as keeping track of                                                              
  expenses or paying bills)?                                                       

  Shopping for personal      1              2                4            -7       -8
  items (such as toilet                                                            
  items or medicines)?                                                             

  Driving?                   1              2                4            -7       -8

  Using public               1              2                4            -7       -8
  transportation?                                                                  

  Using the toilet,          1              2                4            -7       -8
  including getting to the                                                         
  toilet?                                                                          

  Dressing?                  1              2                4            -7       -8

  Bathing or showering?      1              2                4            -7       -8

  Getting into and out of    1              2                4            -7       -8
  bed?                                                                             

  Eating?                    1              2                4            -7       -8
  -------------------------- -------------- ---------------- ------------ -------- --------

60\. Would you say your health in general is excellent, very good, good,
fair, or poor?

> EXCELLENT 1
>
> VERY GOOD 2
>
> GOOD 3
>
> FAIR 4
>
> POOR 5
>
> REFUSED -7
>
> DON'T KNOW -8

61\. In the past 12 months, how often did you feel sad or depressed?
Would you say you were sad or depressed . . .

> All of the time, 1
>
> Some of the time, 2
>
> A little of the time, or 3
>
> None of the time? 4
>
> REFUSED -7
>
> DON'T KNOW -8

62\. Compared to your own level of physical activity 1 year ago, would
you say you are now more active, less active, or about the same as you
were then?

> MORE ACTIVE 1
>
> LESS ACTIVE 2
>
> ABOUT THE SAME 3
>
> REFUSED -7
>
> DON'T KNOW -8

63\. What is the highest level of education you've completed?

> LESS THAN HIGH SCHOOL COMPLETED 1
>
> HIGH SCHOOL GRADUATE OR GED 2
>
> SOME COLLEGE (NO DEGREE) 3
>
> ASSOCIATE DEGREE (AA) 4
>
> COLLEGE GRADUATE (BA, BS) 5
>
> GRADUATE STUDY 6
>
> GRADUATE DEGREE (MA, MS, MBA,
>
> PHD) 7
>
> VOCATIONAL OR TRADE SCHOOL 8
>
> OTHER 9
>
> (SPECIFY)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> REFUSED -7
>
> DON'T KNOW -8

64\. Are you of Spanish, Hispanic, or Latino origin?

> YES 1
>
> NO 2
>
> REFUSED -7
>
> DON'T KNOW -8

65\. Would you classify your race as . . .

> White, 1
>
> Black or African American, 2
>
> Asian, 3
>
> Native Hawaiian or Pacific Islander, or 4
>
> Native American or Alaskan Native? 5
>
> OTHER? 91
>
> (SPECIFY)
>
> REFUSED -7
>
> DON'T KNOW -8

66a. Are you currently employed?

> YES 1
>
> NO 2 
>
> REFUSED -7  GO TO Q.67
>
> DON'T KNOW -8 

b\. Are you currently employed full time, that is 35 hours a week or
more, or part time?

> FULL TIME 1
>
> PART TIME 2
>
> REFUSED -7
>
> DON'T KNOW -8

67\. What is your current marital status?

> MARRIED 1
>
> NEVER MARRIED 2
>
> WIDOWED 3
>
> SEPARATED OR DIVORCED 4
>
> REFUSED -7
>
> DON'T KNOW -8

68\. How many people, including yourself, live in your household?

> NUMBER \|\_\_\_\|\_\_\_\|
>
> REFUSED -7
>
> DON'T KNOW -8

69\. Information about income is a common way of measuring available
financial resources. Considering income from all sources, including
salary, wages, Social Security, welfare, and any other income, what was
your total household income before taxes for 2000? Would you say . . .

> Less than \$8,000 1
>
> \$8,001 - \$10,000 2
>
> \$10,001 - \$20,000 3
>
> \$20,001 - \$40,000 4
>
> \$40,001 - \$60,000 5
>
> \$60,001 - \$80,000 6
>
> Over \$80,000 7
>
> REFUSED -7
>
> DON'T KNOW -8

That's all the questions I have for you. Thank you very much for taking
the time to speak with me. Your opinions are very important in helping
us improve or expand independent living services and independent living
centers.

CONTINUE TO NEXT PAGE.

"Please give me the name you would like on your \$10 check, and the
address you would like us to send the check to."

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Title (Mr, Mrs, Ms, etc) First Name Last Name

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Street Number Street Name Apt. Number

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City State Zip Code

\_\_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Area Code Telephone Number

IF INTERPRETER/TRANSLATOR USED:

"Please give me the name you would like on your \$50 check, and the
address you would like us to send the check to."

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Title (Mr, Mrs, Ms, etc) First Name Last Name

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Street Number Street Name Apt. Number

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City State Zip Code

\_\_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Area Code Telephone Number

**APPENDIX D**

**EXECUTIVE DIRECTOR SURVEY**

**APPENDIX D**

+-----------------------------------------------------------------------+
| **EVALUATION OF THE CENTERS FOR INDEPENDENT LIVING PROGRAM**          |
|                                                                       |
| **SURVEY FOR IL DIRECTORS**                                           |
+-----------------------------------------------------------------------+

(For an electronic copy of this survey, please contact Marcie Goldstein
at marcieg@cessi.net)

**Introduction**

The Rehabilitation Services Administration (RSA), Department of
Education is conducting a national evaluation of Centers for Independent
Living. The purpose of this evaluation is to gain an overall picture of
IL program activities, consumer and community outcomes, and consumer
satisfaction. We are assessing the independent living program as a
[whole]{.underline} rather than comparing any particular center to
another. We are speaking with center consumers and surveying executive
directors for this study.

Your answers will be treated with the strictest confidence. No one
outside the organization conducting the study will see your answers.

We estimate that this survey should take 45-60 minutes to complete. The
survey consists of eight short sections:

Independent Living Philosophy

Services and Community Change/Impact

Diversity

Board of Directors

Staff Training

Relationships with Other Agencies/Organizations

Evaluation and Monitoring

Resources and Funding

Some questions will ask you to check the appropriate box, while others
require a short answer. Please keep your answers short and please
**print legibly**. If you would prefer to complete this survey by
telephone or by e-mail, please call Marcie Goldstein at (703) 448-6155
or e-mail her at marcieg@cessi.net.

\[ID \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\]

**I. INDEPENDENT LIVING PHILOSOPHY**

1.  What does your center believe are the basic components of the
    independent living movement's philosophy?

    **II. SERVICES AND COMMUNITY CHANGE/IMPACT**

2\. Below is a list of methods used to assess community needs for center
services and advocacy. How useful have these methods been in assessing
community needs at your center? (Please circle one number for each
method.)

  ------------ ------------------------------------- ------------------------
  **Method**                                         **RATE**

                                                     **1 = Not at to 5 =
                                                     Very\
                                                     all Useful Useful**
  ------------ ------------------------------------- ------------------------

a\. Analysis of census or other existing data 1 2 3 4 5

b\. Consumer needs survey 1 2 3 4 5

c\. Board/staff planning process 1 2 3 4 5

d\. Community forum 1 2 3 4 5

e\. Expectations/availability of funding sources 1 2 3 4 5

f\. Contacts with community agencies 1 2 3 4 5

g\. Contacts with disability/consumer groups 1 2 3 4 5

h\. Other (please specify) 1 2 3 4 5

3\. Please indicate whether or not your center provides each of the
following services.

  ------------- -------------------------------------- -----------------------
  **Service**                                          **[YES]{.underline}
                                                       [NO]{.underline}**

  ------------- -------------------------------------- -----------------------

a\. Peer counseling 1 2

b\. Information & referral 1 2

c\. Group support 1 2

d\. Benefits advisement 1 2

e\. Legal advisement 1 2

f\. IL skills training 1 2

g\. Housing referral or assistance 1 2

h\. Personal assistance services or referral 1 2

i\. Assistance with modifications at home 1 2

j\. Employment training or referral 1 2

k\. Transition from school to work or independent living 1 2

l\. Education/Literacy/GED 1 2

m\. Assistance acquiring technology or adaptive equipment 1 2

n\. Technical assistance on access 1 2

o\. Individual advocacy 1 2

p\. ADA training 1 2

q\. Advocacy training 1 2

r\. Interpreter services 1 2

s\. Transportation (other than to and from the center) 1 2

t\. Services for specific disability groups 1 2

(please specify group)

u\. Systems advocacy 1 2

v\. Other (please specify) 1 2

w\. Other (please specify) 1 2

x\. Other (please specify) 1 2

4\. Please complete the following table about disability issues. For
each issue, please indicate:

-   Whether or not your center worked on it in Fiscal Year 2000;

-   IF YOUR CENTER WORKED ON AN ISSUE:

-   whether it was at the federal, state, or local level, how much time
    your center spent on it; activities to achieve change, and groups
    who were involved in that change.

+---------+------+---------+----------+----------------+-------------+
|         |      |         |          | **If YES in    |             |
|         |      |         |          | Col. A:**      |             |
+---------+------+---------+----------+----------------+-------------+
|         | **   | **Col.  | **Col.   | **Col. D**     | **Col. E**  |
|         | Col. | B.**    | C**      |                |             |
|         | A**  |         |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| **      | **Wo | **If    | **Amount | **Activity to  | **Groups    |
| Issue** | rked | Col. A  | of time  | achieve        | involved in |
|         | on\  | is      | spent?\  | change\        | advocacy\   |
|         | in   | YES,\   | Rate**   | ( all that    | ( all that |
|         | last | L       |          | apply)**       | apply)**    |
|         | ye   | evel?** | **1 =    |                |             |
|         | ar?\ |         | Little   |                |             |
|         | (Ci  | **      | to 5 = A |                |             |
|         | rcle | (Circle | lot**    |                |             |
|         | on   | yes or\ |          |                |             |
|         | e)** | no for  | *        |                |             |
|         |      | each)** | *(Circle |                |             |
|         |      |         | one)**   |                |             |
|         |      | **Yes   |          |                |             |
|         |      | No**    |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| D       | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| einstit | 1    | 1 2     | 5        | agency or      |             |
| utional |      |         |          | organizational | Board       |
| ization | No 2 | State 1 |          | r              |             |
|         |      | 2       |          | epresentatives | Staff       |
|         |      |         |          |                |             |
|         |      | Local 1 |          | Worked with    | Other       |
|         |      | 2       |          | decision       | disability  |
|         |      |         |          | makers, such   | org         |
|         |      |         |          | as agency      | anizations\ |
|         |      |         |          | administrators | or agencies |
|         |      |         |          | or elected     |             |
|         |      |         |          | officials      | Non         |
|         |      |         |          |                | -disability |
|         |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or organizers  |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)\     |             |
+---------+------+---------+----------+----------------+-------------+

4\. (continued)

+---------+------+---------+----------+----------------+-------------+
|         |      |         |          | **If YES in    |             |
|         |      |         |          | Col. A:**      |             |
+---------+------+---------+----------+----------------+-------------+
|         | **   | **Col.  | **Col.   | **Col. D**     | **Col. E**  |
|         | Col. | B.**    | C**      |                |             |
|         | A**  |         |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| **      | **Wo | **If    | **Amount | **Activity to  | **Groups    |
| Issue** | rked | Col. A  | of time  | achieve        | involved in |
|         | on\  | is      | spent?\  | change\        | advocacy\   |
|         | in   | YES,\   | Rate**   | ( all that    | ( all that |
|         | last | L       |          | apply)**       | apply)**    |
|         | ye   | evel?** | **1 =    |                |             |
|         | ar?\ |         | Little   |                |             |
|         | (Ci  | **      | to 5 = A |                |             |
|         | rcle | (Circle | lot**    |                |             |
|         | on   | yes or\ |          |                |             |
|         | e)** | no for  | *        |                |             |
|         |      | each)** | *(Circle |                |             |
|         |      |         | one)**   |                |             |
|         |      | **Yes   |          |                |             |
|         |      | No**    |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| Int     | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| egrated | 1    | 1 2     | 5        | agency or      |             |
| co      |      |         |          | organizational | Board       |
| mmunity | No 2 | State 1 |          | r              |             |
| housing |      | 2       |          | epresentatives | Staff       |
|         |      |         |          |                |             |
|         |      | Local 1 |          | Worked with    | Other       |
|         |      | 2       |          | decision       | disability  |
|         |      |         |          | makers, such   | org         |
|         |      |         |          | as agency      | anizations\ |
|         |      |         |          | administrators | or agencies |
|         |      |         |          | or elected     |             |
|         |      |         |          | officials      | Non         |
|         |      |         |          |                | -disability |
|         |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or\            |             |
|         |      |         |          | organizers     |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)      |             |
+---------+------+---------+----------+----------------+-------------+
| Transpo | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| rtation | 1    | 1 2     | 5        | agency or      |             |
|         |      |         |          | organizational | Board       |
|         | No 2 | State 1 |          | r              |             |
|         |      | 2       |          | epresentatives | Staff       |
|         |      |         |          |                |             |
|         |      | Local 1 |          | Worked with    | Other       |
|         |      | 2       |          | decision       | disability  |
|         |      |         |          | makers, such   | org         |
|         |      |         |          | as agency      | anizations\ |
|         |      |         |          | administrators | or agencies |
|         |      |         |          | or elected     |             |
|         |      |         |          | officials      | Non         |
|         |      |         |          |                | -disability |
|         |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or\            |             |
|         |      |         |          | organizers     |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)      |             |
+---------+------+---------+----------+----------------+-------------+

4\. (continued)

+---------+------+---------+----------+----------------+-------------+
|         |      |         |          | **If YES in    |             |
|         |      |         |          | Col. A:**      |             |
+---------+------+---------+----------+----------------+-------------+
|         | **   | **Col.  | **Col.   | **Col. D**     | **Col. E**  |
|         | Col. | B.**    | C**      |                |             |
|         | A**  |         |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| **      | **Wo | **If    | **Amount | **Activity to  | **Groups    |
| Issue** | rked | Col. A  | of time  | achieve        | involved in |
|         | on\  | is      | spent?\  | change\        | advocacy\   |
|         | in   | YES,\   | Rate**   | ( all that    | ( all that |
|         | last | L       |          | apply)**       | apply)**    |
|         | ye   | evel?** | **1 =    |                |             |
|         | ar?\ |         | Little   |                |             |
|         | (Ci  | **      | to 5 = A |                |             |
|         | rcle | (Circle | lot**    |                |             |
|         | on   | yes or\ |          |                |             |
|         | e)** | no for  | *        |                |             |
|         |      | each)** | *(Circle |                |             |
|         |      |         | one)**   |                |             |
|         |      | **Yes   |          |                |             |
|         |      | No**    |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| P       | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| ersonal | 1    | 1 2     | 5        | agency or      |             |
| ass     |      |         |          | organizational | Board       |
| istance | No 2 | State 1 |          | r              |             |
| s       |      | 2       |          | epresentatives | Staff       |
| ervices |      |         |          |                |             |
|         |      | Local 1 |          | Worked with    | Other       |
|         |      | 2       |          | decision       | disability  |
|         |      |         |          | makers, such   | org         |
|         |      |         |          | as agency      | anizations\ |
|         |      |         |          | administrators | or agencies |
|         |      |         |          | or elected     |             |
|         |      |         |          | officials      | Non         |
|         |      |         |          |                | -disability |
|         |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or\            |             |
|         |      |         |          | organizers     |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)      |             |
+---------+------+---------+----------+----------------+-------------+
| F       | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| ederal, | 1    | 1 2     | 5        | agency or      |             |
| state,  |      |         |          | organizational | Board       |
| or      | No 2 | State 1 |          | r              |             |
| local   |      | 2       |          | epresentatives | Staff       |
| civil   |      |         |          |                |             |
| rights  |      | Local 1 |          | Worked with    | Other       |
| laws,   |      | 2       |          | decision       | disability  |
| in      |      |         |          | makers, such   | org         |
| cluding |      |         |          | as agency      | anizations\ |
| p       |      |         |          | administrators | or agencies |
| hysical |      |         |          | or elected     |             |
| and     |      |         |          | officials      | Non         |
| program |      |         |          |                | -disability |
| access  |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or\            |             |
|         |      |         |          | organizers     |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)      |             |
+---------+------+---------+----------+----------------+-------------+

4\. (continued)

+---------+------+---------+----------+----------------+-------------+
|         |      |         |          | **If YES in    |             |
|         |      |         |          | Col. A:**      |             |
+---------+------+---------+----------+----------------+-------------+
|         | **   | **Col.  | **Col.   | **Col. D**     | **Col. E**  |
|         | Col. | B.**    | C**      |                |             |
|         | A**  |         |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| **      | **Wo | **If    | **Amount | **Activity to  | **Groups    |
| Issue** | rked | Col. A  | of time  | achieve        | involved in |
|         | on\  | is      | spent?\  | change\        | advocacy\   |
|         | in   | YES,\   | Rate**   | ( all that    | ( all that |
|         | last | L       |          | apply)**       | apply)**    |
|         | ye   | evel?** | **1 =    |                |             |
|         | ar?\ |         | Little   |                |             |
|         | (Ci  | **      | to 5 = A |                |             |
|         | rcle | (Circle | lot**    |                |             |
|         | on   | yes or\ |          |                |             |
|         | e)** | no for  | *        |                |             |
|         |      | each)** | *(Circle |                |             |
|         |      |         | one)**   |                |             |
|         |      | **Yes   |          |                |             |
|         |      | No**    |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| Health  | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| care    | 1    | 1 2     | 5        | agency or      |             |
|         |      |         |          | organizational | Board       |
|         | No 2 | State 1 |          | r              |             |
|         |      | 2       |          | epresentatives | Staff       |
|         |      |         |          |                |             |
|         |      | Local 1 |          | Worked with    | Other       |
|         |      | 2       |          | decision       | disability  |
|         |      |         |          | makers, such   | org         |
|         |      |         |          | as agency      | anizations\ |
|         |      |         |          | administrators | or agencies |
|         |      |         |          | or elected     |             |
|         |      |         |          | officials      | Non         |
|         |      |         |          |                | -disability |
|         |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or\            |             |
|         |      |         |          | organizers     |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)      |             |
+---------+------+---------+----------+----------------+-------------+
| Ed      | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| ucation | 1    | 1 2     | 5        | agency or      |             |
|         |      |         |          | organizational | Board       |
|         | No 2 | State 1 |          | r              |             |
|         |      | 2       |          | epresentatives | Staff       |
|         |      |         |          |                |             |
|         |      | Local 1 |          | Worked with    | Other       |
|         |      | 2       |          | decision       | disability  |
|         |      |         |          | makers, such   | org         |
|         |      |         |          | as agency      | anizations\ |
|         |      |         |          | administrators | or agencies |
|         |      |         |          | or elected     |             |
|         |      |         |          | officials      | Non         |
|         |      |         |          |                | -disability |
|         |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or\            |             |
|         |      |         |          | organizers     |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)      |             |
+---------+------+---------+----------+----------------+-------------+

4\. (continued)

+---------+------+---------+----------+----------------+-------------+
|         |      |         |          | **If YES in    |             |
|         |      |         |          | Col. A:**      |             |
+---------+------+---------+----------+----------------+-------------+
|         | **   | **Col.  | **Col.   | **Col. D**     | **Col. E**  |
|         | Col. | B.**    | C**      |                |             |
|         | A**  |         |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| **      | **Wo | **If    | **Amount | **Activity to  | **Groups    |
| Issue** | rked | Col A   | of time  | achieve        | involved in |
|         | on\  | is      | spent?\  | change\        | advocacy\   |
|         | in   | YES,\   | Rate**   | ( all that    | ( all that |
|         | last | L       |          | apply)**       | apply)**    |
|         | ye   | evel?** | **1 =    |                |             |
|         | ar?\ |         | Little   |                |             |
|         | (Ci  | **      | to 5 = A |                |             |
|         | rcle | (Circle | lot**    |                |             |
|         | on   | yes or\ |          |                |             |
|         | e)** | no for  | *        |                |             |
|         |      | each)** | *(Circle |                |             |
|         |      |         | one)**   |                |             |
|         |      | **Yes   |          |                |             |
|         |      | No**    |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| Emp     | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| loyment | 1    | 1 2     | 5        | agency or      |             |
|         |      |         |          | organizational | Board       |
|         | No 2 | State 1 |          | r              |             |
|         |      | 2       |          | epresentatives | Staff       |
|         |      |         |          |                |             |
|         |      | Local 1 |          | Worked with    | Other       |
|         |      | 2       |          | decision       | disability  |
|         |      |         |          | makers, such   | org         |
|         |      |         |          | as agency      | anizations\ |
|         |      |         |          | administrators | or agencies |
|         |      |         |          | or elected     |             |
|         |      |         |          | officials      | Non         |
|         |      |         |          |                | -disability |
|         |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or\            |             |
|         |      |         |          | organizers     |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)      |             |
+---------+------+---------+----------+----------------+-------------+
| Youth   | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| tra     | 1    | 1 2     | 5        | agency or      |             |
| nsition |      |         |          | organizational | Board       |
|         | No 2 | State 1 |          | r              |             |
|         |      | 2       |          | epresentatives | Staff       |
|         |      |         |          |                |             |
|         |      | Local 1 |          | Worked with    | Other       |
|         |      | 2       |          | decision       | disability  |
|         |      |         |          | makers, such   | org         |
|         |      |         |          | as agency      | anizations\ |
|         |      |         |          | administrators | or agencies |
|         |      |         |          | or elected     |             |
|         |      |         |          | officials      | Non         |
|         |      |         |          |                | -disability |
|         |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or\            |             |
|         |      |         |          | organizers     |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)      |             |
+---------+------+---------+----------+----------------+-------------+

4\. (continued)

+---------+------+---------+----------+----------------+-------------+
|         |      |         |          | **If YES in    |             |
|         |      |         |          | Col. A:**      |             |
+---------+------+---------+----------+----------------+-------------+
|         | **   | **Col.  | **Col.   | **Col. D**     | **Col. E**  |
|         | Col. | B.**    | C**      |                |             |
|         | A**  |         |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| **      | **Wo | **If    | **Amount | **Activity to  | **Groups    |
| Issue** | rked | Col A   | of time  | achieve        | involved in |
|         | on\  | is      | spent?\  | change\        | advocacy\   |
|         | in   | YES,\   | Rate**   | ( all that    | ( all that |
|         | last | L       |          | apply)**       | apply)**    |
|         | ye   | evel?** | **1 =    |                |             |
|         | ar?\ |         | Little   |                |             |
|         | (Ci  | **      | to 5 = A |                |             |
|         | rcle | (Circle | lot**    |                |             |
|         | on   | yes or\ |          |                |             |
|         | e)** | no for  | *        |                |             |
|         |      | each)** | *(Circle |                |             |
|         |      |         | one)**   |                |             |
|         |      | **Yes   |          |                |             |
|         |      | No**    |          |                |             |
+---------+------+---------+----------+----------------+-------------+
| Other   | Yes  | Federal | 1 2 3 4  | Worked with    | Consumers   |
| (please | 1    | 1 2     | 5        | agency or      |             |
| s       |      |         |          | organizational | Board       |
| pecify) | No 2 | State 1 |          | r              |             |
|         |      | 2       |          | epresentatives | Staff       |
| \_\     |      |         |          |                |             |
| _\_\_\_ |      | Local 1 |          | Worked with    | Other       |
| \_\_\_\ |      | 2       |          | decision       | disability  |
| _\_\_\_ |      |         |          | makers, such   | org         |
| \_\_\_\ |      |         |          | as agency      | anizations\ |
| _\_\_\_ |      |         |          | administrators | or agencies |
|         |      |         |          | or elected     |             |
|         |      |         |          | officials      | Non         |
|         |      |         |          |                | -disability |
|         |      |         |          | Worked with    | org         |
|         |      |         |          | the media      | anizations\ |
|         |      |         |          |                | or agencies |
|         |      |         |          | Took legal     |             |
|         |      |         |          | action         | Other       |
|         |      |         |          |                | (please     |
|         |      |         |          | Participated   | specify)    |
|         |      |         |          | in committees  |             |
|         |      |         |          | or working     |             |
|         |      |         |          | groups         |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | demonstrations |             |
|         |      |         |          |                |             |
|         |      |         |          | Conducted      |             |
|         |      |         |          | in-service     |             |
|         |      |         |          | training,\     |             |
|         |      |         |          | accessibility  |             |
|         |      |         |          | surveys, or    |             |
|         |      |         |          | provided\      |             |
|         |      |         |          | technical      |             |
|         |      |         |          | assistance     |             |
|         |      |         |          |                |             |
|         |      |         |          | Trained        |             |
|         |      |         |          | grassroots     |             |
|         |      |         |          | organizations  |             |
|         |      |         |          | or\            |             |
|         |      |         |          | organizers     |             |
|         |      |         |          |                |             |
|         |      |         |          | Other (please  |             |
|         |      |         |          | describe)      |             |
+---------+------+---------+----------+----------------+-------------+

5\. What are the most significant issues for community advocacy/systems
change for your center during the next five years? Please rate the
issues, from one to five, based upon their importance to your center.
"1" is not at all important and "5" is very important.

  ----------- ------------------------------------ --------------------------
  **Issue**                                        **RATE**

                                                   **1 = Not at all to 5 =
                                                   Very\
                                                   Important Important**
  ----------- ------------------------------------ --------------------------

a.  Deinstitutionalization 1 2 3 4 5

b.  Integrated community housing 1 2 3 4 5

c\. Transportation 1 2 3 4 5

d\. Personal Assistance Services 1 2 3 4 5

e\. Civil rights, including physical and program

access 1 2 3 4 5

f\. Health care 1 2 3 4 5

g\. Education 1 2 3 4 5

h\. Employment 1 2 3 4 5

i\. Other (please specify) 1 2 3 4 5

6\. What are the primary barriers to YOUR CENTER in achieving systems
change? Please rate the barriers, from one to five, based upon their
importance. "1" is not at all important and "5" is very important.

  ------------- ------------------------------------ --------------------------
  **Barrier**                                        **RATE**

                                                     **1 = Not at all to 5 =
                                                     Very\
                                                     Important Important**
  ------------- ------------------------------------ --------------------------

a\. Not enough center resources to hire staff 1 2 3 4 5

b\. Lack of knowledgeable staff 1 2 3 4 5

c\. Not enough time to devote to the issue 1 2 3 4 5

d\. Lack of involvement from consumers 1 2 3 4 5

e\. Board concerns 1 2 3 4 5

f\. Concern about center reputation 1 2 3 4 5

g\. Concern about funding 1 2 3 4 5

h\. Resistance of the agency or entity you are\
trying to change 1 2 3 4 5

i\. Lack of agency funding to implement the\
service or program 1 2 3 4 5

j\. Other (please specify) 1 2 3 4 5

7\. What are the primary facilitators to YOUR CENTER in achieving
systems change? Please rate the facilitators, from one to five, based
upon their importance. "1" is not at all important and "5" is very
important.

  ----------------- -------------------------------- --------------------------
  **Facilitator**                                    **RATE**

                                                     **1 = Not at all to 5 =
                                                     Very\
                                                     Important Important**
  ----------------- -------------------------------- --------------------------

a\. Sufficient resources to hire staff 1 2 3 4 5

b\. Staff knowledge and expertise 1 2 3 4 5

c\. Concentrating efforts on a few important issues 1 2 3 4 5

d\. Strong consumer involvement 1 2 3 4 5

e\. Strong board involvement 1 2 3 4 5

f\. Good coalition with other agencies and\
consumer groups 1 2 3 4 5

g\. Allies inside the agency or entity you are\
trying to change 1 2 3 4 5

h\. Political contacts; e.g., Governor, legislators,\
or city council members 1 2 3 4 5

i\. Public support 1 2 3 4 5

j\. Media coverage 1 2 3 4 5

k\. Other (please specify) 1 2 3 4 5

**III. DIVERSITY**

8\. The next few questions relate to ethnic and disability
constituencies served by your center.

<table>
<colgroup>
<col style="width: 15%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 10%" />
<col style="width: 22%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="2"><strong>Constituency</strong></td>
<td rowspan="2"><p><strong>Col. A<br />
Present in<br />
Service Area?</strong></p>
<p><strong>Yes No</strong></p></td>
<td colspan="7"><p><strong>Col. B</strong></p>
<p><strong>If Col. A “Yes,” please rate your degree of success of<br />
each of the following strategies, from <u>1 (low) to 5 (high)</u>.<br />
If you have not used a strategy, please leave it
blank.</strong></p></td>
<td rowspan="2"><p><strong>Col. C<br />
Adequately<br />
Serving?</strong></p>
<p><strong>Yes No</strong></p></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Provided written information in languages other than English?</p>
</blockquote></td>
<td><blockquote>
<p>Employed staff from the constituency you are trying to reach?</p>
</blockquote></td>
<td><blockquote>
<p>Accessed resources to assist people who do not speak English?</p>
</blockquote></td>
<td><blockquote>
<p>Worked with social service agencies that serve a variety of ethnic
groups?</p>
</blockquote></td>
<td><blockquote>
<p>Satellite or branch offices in areas that serve a variety of ethnic
groups?</p>
</blockquote></td>
<td><blockquote>
<p>Worked with community organizations to develop a common advocacy
agenda?</p>
</blockquote></td>
<td><blockquote>
<p>Other (Specify)</p>
</blockquote></td>
<td><strong>If Col. C “No,”<br />
What is the primary<br />
barrier to serving group?</strong></td>
</tr>
<tr class="odd">
<td>White</td>
<td>1 2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1 2</td>
<td></td>
</tr>
<tr class="even">
<td>Black/African American</td>
<td>1 2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1 2</td>
<td></td>
</tr>
<tr class="odd">
<td>Asian/Pacific Islander</td>
<td>1 2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1 2</td>
<td></td>
</tr>
<tr class="even">
<td>Alaskan Native/<br />
Native American</td>
<td>1 2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1 2</td>
<td></td>
</tr>
<tr class="odd">
<td>Hispanic/Latino</td>
<td>1 2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1 2</td>
<td></td>
</tr>
<tr class="even">
<td>Other (Please Specify)</td>
<td>1 2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1 2</td>
<td></td>
</tr>
</tbody>
</table>

9\. Disabilities that are sometimes not served or under served by
centers are listed below. Please indicate, by circling the appropriate
response, whether or not you feel you are adequately serving each of the
listed constituencies. Then, [for those constituencies that you
indicated were not adequately served]{.underline}, rate your success
from **1 (low) to 5 (high)** with reaching the constituency by using
that activity.

+--------------------+-------+-------+----+--------+------+-----+---+
|                    |       | *     |    |        |      |     |   |
|                    |       | *Col. |    |        |      |     |   |
|                    |       | B**   |    |        |      |     |   |
|                    |       |       |    |        |      |     |   |
|                    |       | **If  |    |        |      |     |   |
|                    |       | Col.  |    |        |      |     |   |
|                    |       | A     |    |        |      |     |   |
|                    |       | "No," |    |        |      |     |   |
|                    |       | p     |    |        |      |     |   |
|                    |       | lease |    |        |      |     |   |
|                    |       | rate  |    |        |      |     |   |
|                    |       | your  |    |        |      |     |   |
|                    |       | d     |    |        |      |     |   |
|                    |       | egree |    |        |      |     |   |
|                    |       | of    |    |        |      |     |   |
|                    |       | su    |    |        |      |     |   |
|                    |       | ccess |    |        |      |     |   |
|                    |       | of\   |    |        |      |     |   |
|                    |       | each  |    |        |      |     |   |
|                    |       | of    |    |        |      |     |   |
|                    |       | the   |    |        |      |     |   |
|                    |       | foll  |    |        |      |     |   |
|                    |       | owing |    |        |      |     |   |
|                    |       | s     |    |        |      |     |   |
|                    |       | trate |    |        |      |     |   |
|                    |       | gies, |    |        |      |     |   |
|                    |       | from  |    |        |      |     |   |
|                    |       | [1    |    |        |      |     |   |
|                    |       | (low) |    |        |      |     |   |
|                    |       | to 5  |    |        |      |     |   |
|                    |       | (     |    |        |      |     |   |
|                    |       | high) |    |        |      |     |   |
|                    |       | ]{.un |    |        |      |     |   |
|                    |       | derli |    |        |      |     |   |
|                    |       | ne}.\ |    |        |      |     |   |
|                    |       | If    |    |        |      |     |   |
|                    |       | you   |    |        |      |     |   |
|                    |       | have  |    |        |      |     |   |
|                    |       | not   |    |        |      |     |   |
|                    |       | used  |    |        |      |     |   |
|                    |       | a     |    |        |      |     |   |
|                    |       | stra  |    |        |      |     |   |
|                    |       | tegy, |    |        |      |     |   |
|                    |       | p     |    |        |      |     |   |
|                    |       | lease |    |        |      |     |   |
|                    |       | leave |    |        |      |     |   |
|                    |       | it    |    |        |      |     |   |
|                    |       | bla   |    |        |      |     |   |
|                    |       | nk.** |    |        |      |     |   |
+--------------------+-------+-------+----+--------+------+-----+---+
| **Constituency**   | *     | > Pr  | >  | >      | >    | > W | > |
|                    | *Col. | ovide | Em | Access | Work | ork |   |
|                    | A**   | > wr  | pl | >      | >    | > w | O |
|                    |       | itten | oy |  speci | with | ith | t |
|                    | **    | > i   | >  | alized | > di | > d | h |
|                    | Adequ | nform |  s | > reso | sabi | isa | e |
|                    | ately | ation | ta | urces, | lity | bil | r |
|                    | Servi | > in  | ff | > such | >    | ity | > |
|                    | ng?** | > a   | >  | > as   | spec | > o |   |
|                    |       | ltern | fr | > sign | ific | rga | ( |
|                    | **Yes | ative | om | > la   | >    | niz | s |
|                    | No**  | > fo  | >  | nguage | agen | ati | p |
|                    |       | rmats |  t | >      | cies | ons | e |
|                    |       | >     | he | interp | >    | >   | c |
|                    |       |  (Bra | >  | reters | that |  to | i |
|                    |       | ille, | co | > or   | > s  | > d | f |
|                    |       | >     | ns | > B    | erve | eve | y |
|                    |       | Tape, | ti | raille | > a  | lop | ) |
|                    |       | > s   | tu | > tea  | > pa | > a |   |
|                    |       | imple | en | chers, | rtic | >   |   |
|                    |       | >     | cy | > to   | ular | com |   |
|                    |       |  lang | >  | > meet | >    | mon |   |
|                    |       | uage, |  y | > sp   | cons | >   |   |
|                    |       | >     | ou | ecific | titu |  ad |   |
|                    |       |  etc) | >  | >      | ency | voc |   |
|                    |       |       |  a |  needs |      | acy |   |
|                    |       |       | re |        |      | >   |   |
|                    |       |       | >  |        |      | age |   |
|                    |       |       | tr |        |      | nda |   |
|                    |       |       | yi |        |      |     |   |
|                    |       |       | ng |        |      |     |   |
|                    |       |       | >  |        |      |     |   |
|                    |       |       | to |        |      |     |   |
|                    |       |       | >  |        |      |     |   |
|                    |       |       |  r |        |      |     |   |
|                    |       |       | ea |        |      |     |   |
|                    |       |       | ch |        |      |     |   |
+--------------------+-------+-------+----+--------+------+-----+---+
| Deaf/Hearing       | 1 2   |       |    |        |      |     |   |
| Impaired           |       |       |    |        |      |     |   |
+--------------------+-------+-------+----+--------+------+-----+---+
| Blind/Visually     | 1 2   |       |    |        |      |     |   |
| Impaired           |       |       |    |        |      |     |   |
+--------------------+-------+-------+----+--------+------+-----+---+
| Psychiatric        | 1 2   |       |    |        |      |     |   |
| Disability         |       |       |    |        |      |     |   |
+--------------------+-------+-------+----+--------+------+-----+---+
| Cognitive          | 1 2   |       |    |        |      |     |   |
| Disability         |       |       |    |        |      |     |   |
+--------------------+-------+-------+----+--------+------+-----+---+
| Multiple Chemical  | 1 2   |       |    |        |      |     |   |
| Sensitivity (MCS)  |       |       |    |        |      |     |   |
| or environmental   |       |       |    |        |      |     |   |
| illness            |       |       |    |        |      |     |   |
+--------------------+-------+-------+----+--------+------+-----+---+
| Other (please      | 1 2   |       |    |        |      |     |   |
| specify)           |       |       |    |        |      |     |   |
+--------------------+-------+-------+----+--------+------+-----+---+

10\. Please indicate whether or not your center provides the following
alternative communication methods.

  ------------ -------------------------------------- -----------------------
  **Method**                                          **[YES]{.underline}
                                                      [NO]{.underline}**

  ------------ -------------------------------------- -----------------------

a\. Large print 1 2

b\. Braille 1 2

c\. Cassette tape 1 2

d\. Computer disk 1 2

e\. Sign language interpreter 1 2

f\. Simplified English 1 2

g\. CART Reporting 1 2

11\. To what extent is your center able to meet all requests for
alternative communication? (Please circle the appropriate number.)

  -------------- -------------- -------------- -------------- --------------
  1\             2              3              4              5\
  **Not\                                                      **Fully\
  Able**                                                      Able**

  -------------- -------------- -------------- -------------- --------------

12\. Is your center accessible by public transportation or paratransit
services?

Yes 1

No 2

There are no public

transportation services in our

community 3

13\. Would you say that your center's service area is ...

Urban 1

Suburban 2

Rural 3

Mixed 4

**IV. BOARD OF DIRECTORS**

14\. Board members can be recruited in many ways. Some possible sources
of good board members are listed below. Please indicate how successful
your center has found each recruitment source to be by circling the
appropriate number for each source.

+--------------------------------+-----+-----+-----+-----+---------+
| **Source**                     | **U |     |     |     |         |
|                                | sef |     |     |     |         |
|                                | uln |     |     |     |         |
|                                | ess |     |     |     |         |
|                                | in  |     |     |     |         |
|                                | R   |     |     |     |         |
|                                | ecr |     |     |     |         |
|                                | uit |     |     |     |         |
|                                | ing |     |     |     |         |
|                                | Bo  |     |     |     |         |
|                                | ard |     |     |     |         |
|                                | Mem |     |     |     |         |
|                                | ber |     |     |     |         |
|                                | s** |     |     |     |         |
+--------------------------------+-----+-----+-----+-----+---------+
|                                | **  | **  | **  | **V | **Exce  |
|                                | Poo | Fai | Goo | ery | llent** |
|                                | r** | r** | d** | Goo |         |
|                                |     |     |     | d** |         |
+--------------------------------+-----+-----+-----+-----+---------+
| Disability Organization        | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+
| Former Staff                   | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+
| Recommendations of Board       | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+
| Recommendations of Staff       | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+
| Human Service Agencies         | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+
| Elected Officials              | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+
| Consumers                      | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+
| Relatives of Consumers         | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+
| Representatives of Center      | 1   | 2   | 3   | 4   | 5       |
| funding Sources                |     |     |     |     |         |
+--------------------------------+-----+-----+-----+-----+---------+
| Private Business               | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+
| Other (please specify)         | 1   | 2   | 3   | 4   | 5       |
|                                |     |     |     |     |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_     |     |     |     |     |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |     |     |     |     |         |
+--------------------------------+-----+-----+-----+-----+---------+
| Other                          | 1   | 2   | 3   | 4   | 5       |
+--------------------------------+-----+-----+-----+-----+---------+

15\. Which statement best describes the type of training your center
conducts for board members?

We do not conduct formal board training. Board\
members learn through participation on the board 1

We conduct board training using center board and\
staff members 2

We bring in an expert on board development or on\
independent living to conduct board training 3

Other (please specify) 4

16\. How effective would you say this board training has been in
assisting your board to fulfill the center's mission?

Very effective 1

Somewhat effective 2

Neutral 3

Somewhat ineffective 4

Very ineffective 5

17\. How would you characterize the relationship between YOUR CENTER'S
board and staff members?

Very positive/supportive 1

Somewhat positive/supportive 2

Neutral 3 ** GO TO Q.20**

Somewhat adversarial 4

Very adversarial 5 **(GO TO Q.19)**

18\. What factors do you think contribute most to a positive working
relationship between YOUR CENTER'S board and staff?

19\. What factors do you think contribute most to an adversarial
relationship between a center's board and staff members?

**V. STAFF TRAINING**

20\. With your experience in running a center and in understanding the
experiences of other center directors, what would you identify as the
three issues that make the difference between success and failure for
CILs?

1\.

2\.

3\.

21\. Describe the three most pressing training needs of YOUR CIL.

1\.

2\.

3\.

22\. Describe the three most pressing technical assistance needs of YOUR
CIL.

1\.

2\.

3\.

23\. Please tell us the three IL-related topics which you would most
like to read about in newsletters, guides, and journals.

1\.

2\.

3\.

**VI. RELATIONSHIPS WITH OTHER AGENCIES**

24a. To what extent is the Designated State Unit (DSU) supportive of
your CIL? The DSU is the agency that provides vocational rehabilitation
services under Title I of the Rehabilitation Act, generally referred to
as the State Rehabilitation Agency or the Department of Rehabilitation
Services? (Circle one)

Very supportive 1

Somewhat supportive 2 **(GO TO Q.24b)**

Neutral 3  **(GO TO Q.24d)**

Somewhat adversarial 4

Very adversarial 5 **(GO TO Q.24c)**

No relationship 6

Other (please specify) 7 **(GO TO Q.24d)**

24b. What factors do you think have contributed most to the supportive
nature of the relationship between your center and the DSU?

**(GO TO Q.24d)**

24c. What factors do you think have contributed to the adversarial
nature of the relationship between your center and the DSU?

24d. What actions, if any, could RSA take to foster a positive
relationship between your center and the DSU?

**The next few questions focus on the State Independent Living Council
(SILC).**

25\. Which statement(s) describes your representation on the SILC?

  --------------- ------------------------------------ -----------------------
  **Statement**                                        **[YES]{.underline}
                                                       [NO]{.underline}**

  --------------- ------------------------------------ -----------------------

a\. I serve on the SILC 1 2

b\. A member of the center's staff serves on the SILC 1 2

c\. A member of the center's board of directors serves\
on the SILC 1 2

d\. A consumer affiliated with the center serves on the SILC 1 2

e\. I elect someone who represents centers for\
independent living to serve on the SILC 1 2

f\. I have no representation on the SILC 1 2

g\. Other (please specify) 1 2

26\. Please rate the SILC in your state on the following SILC purposes
by circling the appropriate number for each statement.

  ----------------------------- ---------- ---------- ---------- -------- --------------- ---------
  **Purpose**                   **SILC                                                    
                                Rating**                                                  

                                **Poor**   **Fair**   **Good**   **Very   **Excellent**   **Don't
                                                                 Good**                   Know**

  Outreach to unserved and      1          2          3          4        5               8
  underserved populations                                                                 

  Assessment of community needs 1          2          3          4        5               8

  Obtaining consumer input on   1          2          3          4        5               8
  the state IL plan                                                                       

  Development of the state IL   1          2          3          4        5               8
  plan                                                                                    

  Oversight and monitoring of   1          2          3          4        5               8
  the state IL plan                                                                       

  Evaluation of the state plan  1          2          3          4        5               8

  Evaluation of consumer        1          2          3          4        5               8
  satisfaction                                                                            

  Development of a network of   1          2          3          4        5               8
  centers for independent                                                                 
  living across the state                                                                 

  Establishing a consumer       1          2          3          4        5               8
  network to advocate for                                                                 
  additional funding, services,                                                           
  or legislation                                                                          
  ----------------------------- ---------- ---------- ---------- -------- --------------- ---------

27\. To what extent would you say the SILC composition meets each of the
following criteria? Please circle the appropriate number for each
criteria.

  -------------------------------- --------------- ---------- ---------- ----------
  **Criteria**                     **SILC                                
                                   Composition**                         

                                   **Not at All**  **To Some  **To a     **Don't
                                                   Extent**   Great      Know**
                                                              Extent**   

  Provides statewide               1               2          3          8
  representation                                                         

  Represents a broad range of      1               2          3          8
  individuals with disabilities                                          
  from diverse backgrounds                                               

  Individuals are knowledgeable    1               2          3          8
  about centers for independent                                          
  living and independent living                                          
  services                                                               

  A majority of members are        1               2          3          8
  individuals with disabilities                                          
  who do not work for any state                                          
  agency or center for independent                                       
  living                                                                 
  -------------------------------- --------------- ---------- ---------- ----------

28a. To what extent is the SILC supportive of your center?

Very supportive 1

Somewhat supportive 2 **(GO TO Q.28b)**

Neutral 3  **(GO TO Q.28d)**

Somewhat adversarial 4

Very adversarial 5 **(GO TO Q.28c)**

No relationship 6

Other (please specify) 7 **(GO TO Q.28d)**

28b. What factors do you think have contributed most to the supportive
nature of the relationship between your center and the SILC?

**(GO TO Q.28d)**

28c. What factors do you think have contributed to the adversarial
nature of the relationship between your center and the SILC?

28d. What actions, if any, could RSA take to foster a positive
relationship between your center and the SILC?

29a. Some states have a state rehabilitation agency serving people who
are blind or visually impaired that is separate from the rehabilitation
agency that serves people with other disabilities. Do you have a
separate agency for the blind in your state?

Yes 1

No 2  **(GO TO Q.30)**

29b. To what extent is the agency for the blind supportive of your CIL?

Very supportive 1

Somewhat supportive 2

Neutral 3  **(GO TO Q.29e)**

Somewhat adversarial 4

Very adversarial 5 **(GO TO Q.29d)**

No relationship 6

Other (please specify) 7 **(GO TO Q.29e)**

29c. What factors do you think have contributed most to the supportive
nature of the relationship between your center and the state agency for
the blind?

**(GO TO Q.30)**

29d. What factors do you think have contributed to the adversarial
nature of the relationship between your center and the state agency for
the blind?

29e. What actions, if any, could RSA take to foster a positive
relationship between your center and the state agency for the blind?

**VII. EVALUATION AND MONITORING**

The next few questions address the evaluation report required under
Section 704 of the Rehabilitation Act and the periodic site reviews
conducted by RSA or the DSU.

30\. Approximately how many days would you say it takes to prepare for
and complete the 704 Report?

\_\_\_\_\_\_\_\_\_\_\_\_\_

Number of days

31\. How helpful to you and your staff is the information gathered for
the 704 Report in assessing the quality of the services and advocacy
your center provides?

Very helpful 1

Somewhat helpful 2

Neutral 3

Somewhat unhelpful 4

Not helpful 5

32\. What suggestions would you make to improve the 704 Report?

33\. RSA conducts periodic site reviews of each center. Has your center
had a site visit by RSA in the last three years?

Yes 1

No 2  **(GO TO Q.34)**

33a. About how many days would you say it took to prepare for and
complete the RSA site review?

\_\_\_\_\_\_\_\_\_\_\_\_\_

Number of days

33b. How helpful is the RSA site review process in assessing the quality
of the services and advocacy your center provides?

Very helpful 1

Somewhat helpful 2

Neutral 3

Somewhat unhelpful 4

Not helpful 5

33c. What suggestions would you make to improve the RSA site review?

34\. DSUs also conduct periodic site reviews or other ongoing monitoring
activities. Has your center had a review by your DSU in the last three
years?

Yes 1

No 2  **(GO TO Q.35)**

34b. About how many days would you say it took to prepare for and
complete the DSU review?

\_\_\_\_\_\_\_\_\_\_\_\_\_

Number of days

34c. How helpful is the DSU review process in assessing the quality of
the services and advocacy your center provides?

Very helpful 1

Somewhat helpful 2

Neutral 3

Somewhat unhelpful 4

Not helpful 5

34d. What suggestions would you make to improve the DSU review?

**VIII. RESOURCES AND FUNDING**

35\. Please indicate whether or not you received the following sources
of funding in Federal Fiscal Year 2000.

-   Indicate in Col. B whether or not there have been any problems or
    difficulties (e.g., record keeping burden, eligibility rules,
    inconsistencies with IL philosophy, etc.) that have arisen as a
    result of acquiring any of these resources; and

-   Briefly describe the problem in Col. C.

+-----------------------+----------+-----------------+-----------------+
|                       |          | **If YES in     |                 |
|                       |          | Col. A**        |                 |
+-----------------------+----------+-----------------+-----------------+
| **Source**            | **Col.   | **Col. B**      | **Col. C**      |
|                       | A**      |                 |                 |
|                       |          | **Problems or   | **(If YES in    |
|                       | **Rec    | Difficulties?** | Col. B)**       |
|                       | eived?** |                 |                 |
|                       |          | **YES NO**      | **What were     |
|                       | **YES    |                 | they?**         |
|                       | NO**     |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Federal Funds         |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Title VII, Part B,    | 1 2      | 1 2             |                 |
| Chapter1              |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Title VII, Part C,    | 1 2      | 1 2             |                 |
| Chapter 1             |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Title VII, Chapter II | 1 2      | 1 2             |                 |
+-----------------------+----------+-----------------+-----------------+
| Other federal funds   | 1 2      | 1 2             |                 |
+-----------------------+----------+-----------------+-----------------+
|                       |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Other Government      |          |                 |                 |
| Funds                 |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| State government      | 1 2      | 1 2             |                 |
| funds                 |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Local government      | 1 2      | 1 2             |                 |
| funds                 |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
|                       | 1 2      | 1 2             |                 |
+-----------------------+----------+-----------------+-----------------+
| Private Funds         |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Foundations,          | 1 2      | 1 2             |                 |
| corporation, or       |          |                 |                 |
|                       |          |                 |                 |
| trust grants          |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Donations from        | 1 2      | 1 2             |                 |
| individuals           |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Memberships           | 1 2      | 1 2             |                 |
+-----------------------+----------+-----------------+-----------------+
| Investment income     | 1 2      | 1 2             |                 |
+-----------------------+----------+-----------------+-----------------+
| Fee for Service       | 1 2      | 1 2             |                 |
| (program income)      |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+
| Other                 | 1 2      | 1 2             |                 |
| income/resources      |          |                 |                 |
|                       |          |                 |                 |
| (in-kind etc)         |          |                 |                 |
+-----------------------+----------+-----------------+-----------------+

36a. Are there any funds that your center no longer receive with which
you had problems or difficulties?

Yes 1

No 2  **(GO TO Q.37)**

> b\. Please indicate which type of funds your center received and
> briefly describe the difficulties with these funds.

  ----------------------------------- -----------------------------------
  **Type of Fund**                    **Difficulty**

                                      

                                      

                                      

                                      
  ----------------------------------- -----------------------------------

37\. In general, what factors have facilitated the acquisition of other
resources?

38\. What factors have impeded the acquisition of other resources?

39\. Approximately what percentage of your budget is allocated to the
following areas:

**[Budget Area]{.underline}** **[% of Budget Allocated]{.underline}**

Services \_\_\_\_\_\_\_\_\_\_

Systems change advocacy \_\_\_\_\_\_\_\_\_\_

Administration \_\_\_\_\_\_\_\_\_\_

40\. Approximately what percentage of your funding is
discretionary---that is, not linked to a particular service and is
available to be used for advocacy?

\_\_\_\_\_\_\_\_%

**% of Funding that is Discretionary**

Finally, we need a few demographics and contact information in case we
need to contact you to clarify a response.

41\. What is your name and job title?

**Name:**

**Job Title:**

42\. How long have you served in this position?

\_\_\_\_\_\_\_\_

Number of Years

43\. How long have you been affiliated with a center for independent
living, either as a staff person, board member, or consumer?

\_\_\_\_\_\_\_\_

Number of Years

44a. Did anyone else assist you in completing this survey?

Yes 1

No 2  **(GO TO END)**

b\. What is their position at the center?

**Job Title:**

45\. How long has your center been in existence as a non-profit agency
with a board of directors comprised of a majority of people with
disabilities?

\_\_\_\_\_\_\_\_

Number of Years

**Thank you very much for taking the time to complete this survey.
Please return it in the enclosed self-addressed postage-paid envelope
by**

> **DUE DATE**

**or mail to:**

**CESSI**

**Attn: Marcie Goldstein**

**6858 Old Dominion Drive**

**Suite 250**

**McLean, VA 22101**

**APPENDIX E**

**Examples of Community Outcomes from the 704 Reports**

# APPENDIX E

EXAMPLES OF COMMUNITY OUTCOMES

FROM THE FY 2001 704 REPORTS

# 

# 

# 

# 

# PERSONAL ASSISTANCE/DEINSTITUTIONALIZATION

## [Legislation]{.underline}

Passage of HB1197, which requires the state to apply for a Medicaid
waiver for publicly funded assisted living, adult foster care and
expanded day care.

## [Policy]{.underline}

1\. As a result of the center's advocacy, Utah's Director of Medicaid
initiated changes needed to allow individuals who are currently living
in nursing homes but could move into the community with personal
assistance to access services from the Physical Disabilities Medicaid
Waiver without being placed on the waiting list to compete with people
in the community also trying to access funding. This is a major system
change having a two fold benefit for both nursing home residents and
people in the community waiting for personal assistance.

2\. Efforts to develop a plan in our state, which would implement the
Supreme Court decision of the Olmstead Case, began in earnest in
February. It began with Ralph Rouse and others from the Regional Office
of Civil Rights coming to Arkansas and educating both DHS and advocates
on the Supreme Court's decision and its implications. At this first
meeting it was determined to establish an Olmstead Coalition. This
Coalition included advocates, service providers and consumers. SAILS had
staff representation on the Coalition from the beginning. The Coalition,
which met weekly, was successful in holding forums around the state to
educate people and gather input for the development of a state plan.
They also got the Governor to sign an Executive Order for a state plan
to be developed and appoint an Olmstead Work Group. This group met
weekly also. Our representative attended both weekly meetings. These
meetings lasted from February through October, ending with a draft plan
to submit to the state.

## [Service Improvement]{.underline}

1\. As proposed, CRS focused its efforts on a systematic advocacy issue
that affects people with disabilities In Home Support Services (IHSS).
The ELA and CLA Advocate were part of a major effort of a change that
occurred this past year with IHSS. Salaries for IHSS workers have
increased twice, from minimum (\$5.75 per hour) to \$6.25 and finally to
\$6.75. This increase has had a positive impact with the recruitment and
retention of qualified IHSS workers that provide services to persons
with disabilities. The ELA Advocate was involved in this process through
collaboration in monthly IHSS coalition meetings. Last year the Advocate
along with 15-20 consumers participated in a rally concerning IHSS
worker's wages. Additionally, the ELA Advocate participated in a press
conference regarding IHSS issues and was the "Spanish Speaking Voice"
for consumers.

2\. The Center coordinated efforts throughout the state for increased
funding for the Kentucky Personal Care Attendant Program. Advocates
worked statewide to call, visit, and write letters to the legislators
explaining the importance of the program. The effort was successful, and
the program was granted expansion funds to enroll approximately 100 new
consumers. This is just a drop in the bucket for the lengthy waiting
list, but it is a start from the General Assembly with a promise of more
funds to come, and a promise from the consumers of increased advocacy in
the future.

## [Service Maintenance]{.underline}

One other major gain around PCAs that CORD led on behalf of the
coalition was getting language\--for the fifth straight year\--put in
the state budget that prevents the Division of Medical Assistance from
changing the regulations of the PCA program without the input of
disability advocates (representatives of the SILC, Governor's Advisory
Commission on Disability, and the state Office on Disability). This
language has been the pivot point for progressive change and vital
program protection since the mid 1990s.

# 

# HEALTH CARE

## [Communication Access]{.underline}

The Walker County staff advocated for qualified interpreters for
individuals with hearing impairments with the Walker Baptist Medical
Center.

## [Legislation]{.underline}

ABIL worked with a Health Care Reform Coalition during the 2000
legislative session to pass a HMO Reform bill that included 1) that
HMO's had to reimburse providers within a time frame, 2) that consumers
had the right to sue HMO's for negligence, 3) that HMO's had to offer
chiropractic care. Consumers got involved by attending a Legislative
Lobby Day with a press conference and visited every member of the
legislature demanding that they pass "real" health care reform.

##  

## [Policy]{.underline}

Adequate health care and personal assistance continue to be top
priorities to HCIL consumers. The Houston Center for Independent Living
has actively participated in efforts to improve health care. During the
year, we held educational meetings on the Star Plus managed care pilot
for consumers. More importantly, we have collaborated in the development
of a new regional model to increase access to long term care as mandated
by Texas Senate Bill 374. HCIL participated in open meeting discussions
with the Texas Department of Human Services, the Area Agency on Aging,
the Texas Department of Health, a representative from the Houston
Mayor's Office on Disability, and service providers to seniors and
people with disabilities. HCIL made recommendations, which have been
incorporated, into the final proposal, reflecting the necessity for
greater consumer control.

## [Service Improvement]{.underline}

1\. Community Based Services for people with psychiatric disabilities:
As a member of a large coalition, called Keeping the Promise, the Center
played a role in the defeat of proposed state legislation that would
made it easier to commit people to involuntary outpatient programs and
involuntary in-patient medication programs. We worked to successfully
secure new appropriations for two community based services for people
with psychiatric disabilities.

2\. TTH staff supported a grass roots effort by local tribal community
members to advocate for needed health care. Indian Health Service (the
primary health care provider) re- interpreted federal regulation which
resulted in 3 tribal communities being excluded from contract health
services (specialty health care services such as ENT, orthopedics,
Neurologists etc). Many of these services are essential for persons with
disabilities. The group was able to address the tribal council demanding
their needs be addressed. This was successful in that a special council
meeting was convened in their local community center to begin to develop
a plan to address the issue.

# 

# HOUSING

## [Monitoring]{.underline}

DAC staff and volunteers helped perform and coordinate Fair Housing
Testing in cooperation with the Intermountain Fair Housing Council. As a
result of these and other enforcement activities, the state of Idaho has
been able to create a fund to assist people with disabilities to make
their homes accessible. The program is coordinated through the

Idaho Housing and Finance Association with CILs assisting consumers with
the application process.

# [Physical Access]{.underline}

The Legal Department received final settlement on two suits that it had
filed concerning accessibility issues. One against Washburn Apartments
for failing to comply with Fair Housing building requirements

## [Policy]{.underline}

1\. As we were working with several coordinated religious groups in the
San Fernando Valley, we were informed that they were supporting Habitat
for Humanity. We discussed the fact that their housing was not being
opened to persons with disabilities. This was for two reasons: 1) the
housing was not designed for accessibility; 2) the policies, procedures,
and eligibility would have excluded persons with disabilities. The
religious groups called on Habitat for Humanity and changes were
adopted. A client of ILCSC was made eligible, and their house has just
been completed.

2\. Liberty Resources and Disabled In Action, as plaintiffs, won a court
decision in their suit against the Philadelphia Housing Authority (PHA).
PHA cannot develop new or renovate existing housing sites unless at
least five percent (5%) of the units are accessible to Persons with
Disabilities.

## [Service Improvement]{.underline}

SMILE requested recommendation from the Yuma Citizens' Advisory
Committee to the City Council for a home modification program for the
city's disabled population. The outcome of this request was that a
Community Development Block Grant was awarded to the CIL to finance this
program.

Through our advocacy, two single family accessible rental homes are
planned using Community Development Block Grant funds, and two CIL
consumers currently living in nursing homes will be offered this housing
option. Partnerships with local realtors and banks have given us entry
to affordable, accessible apartments and single-family homes, as well as
homeownership.

# EDUCATION

## [Communication Access]{.underline}

DAC advocacy efforts promoted the implementation of Richland School
District One in implementing policy and procedure for obtaining
qualified interpreting services for Deaf parents with hearing children
in school. This will enhance the Deaf parent\'s ability to stay involved
in their child\'s education and events at the school.

## [Service Improvement]{.underline}

Parent Advocate responded to several complaints from Families in the
Lyme School District by organizing a meeting. At this meeting, the five
Families in attendance shared their frustrations and identified several
common issues. Parent Advocate provided these Families with background
on the IDEA and on their rights. The parents expressed an interest in
inviting members of the School Board to a subsequent meeting. At this
meeting, attended by the School Board President and another member of
the Board, nine Parents each described their issues while Board members
listened and took notes. Some of the issues identified were not
implementing IEP's, holding CSE meetings without the Parent, failing to
make referrals for evaluations for Children with significant educational
delays, lack of staff training, transportation problems, and failing to
provide Families with their "Parents Guide to Special Education". The
two board members in attendance brought the information back to the rest
of the School Board.

Since the initial meeting of these Parents the following has resulted:

> Parents have formed a Parent-to-Parent Network in the Lyme area and
> are now meeting on a regular basis.

The CSE Chairperson resigned at Lyme Central School

> Several Children have received evaluations that revealed various
> disabilities, qualifying them for Special Education and
>
> A favorable relationship and communication between parents and the
> school board has developed.

## [Service Maintenance]{.underline}

CORD yet again rallied its troops to fight changes in the Massachusetts
special education law, Chapter 766. The group sent a bus load and then
some to a State House hearing in late spring, meeting with six of seven
members of the Cape's legislative delegation. Mailings were also sent to
hundreds, urging them to join in this education campaign. Changes
weakening the law were passed in early summer\--including the phase out
of maximum feasible benefit\--but CORD, as part of an effort coordinated
by the Mass. Advocacy Center, among others, was able to help lessen the
impact, as independent evaluations were saved for low and
moderate-income children and eligibility standards were not gutted, as
had been proposed.

## [Physical Access]{.underline}

The Center placed two ramps at Malabar School that will allow students
who have disabilities to access a project garden. Until the ramps were
placed, these students could not accomplish the hands on study required
in their science studies. With a cooperative agreement with the school
administration, these students now can enjoy the same outside activities
as their classmates.

## [Policy]{.underline}

The center successfully advocated with the Carbon School District for
integrated transportation to and from elementary school on behalf of a
child with muscular dystrophy. The School District wanted the child to
ride on a bus with individuals with mental retardation who attend a
different school instead of with her peers and classmates.

# CIVIL RIGHTS

## [Communication Access]{.underline}

The Walker County staff advocated successfully with the deaf community
for a public TDD at the Jasper mall.

## [Monitoring]{.underline}

In spite of the Americans with Disabilities Act having been law for
better than 10 years, city/county planners, inspectors, and developers
still do not accord close enough attention to the ADAAG. Sources
continues to find itself having to point out deficiencies in a number of
retail establishments after they were given certificates of occupancy
that allows them to be open for business. This has been discouraging
because these were not projects that were just getting a facelift (still
subject to the ADA) but were new construction. To assure that these
unfortunate slipups are non-recurring, we insist that city building
inspection officials accompany us to all sites that we challenge do not
meet the ADA. We do this, so that inspectors can get a first hand
understanding of how important it is to pay close attention to all the
provisions of the accessibility guidelines and that no accommodation,
regardless of how small, should be overlooked. We are encouraged that we
may be having an impact in that we have seen a dramatic increase in
requests for technical assistance in ADA matters from city/ county
building inspectors as well as from architects and developers.

## [Policy]{.underline}

ECCIL provided information and technical assistance to a number of small
businesses and agencies throughout the fiscal year. In addition, a great
deal of follow-up effort went toward resolution of previously-identified
barriers to full participation by persons with disabilities presented by
Whiteco, a multi-billion dollar international corporation which owns
many local hotels, restaurants and recreation centers. Due to its high
visibility and position of influence on other area businesses, as well
as its steadfast refusal to bring its facilities and policies into
compliance with the ADA, Whiteco was selected as an ideal "target" by
which to educate and obtain cooperation from others who also continued
to delay compliance with ADA standards. In response to ECCIL's demands,
Whiteco had contracted with the area DBTAC to conduct a site survey.
Although Whiteco later reported having addressed the majority of the
findings from that survey, local consumers reported otherwise. ECCIL
facilitated a meeting between those consumers and Whiteco
representative, who then agreed to bring the DBTAC out to conduct a
second site survey. The results of that survey support consumer
concerns. At the time this report was prepared, additional meetings were
set for early in the next fiscal year to discuss not only physical
accessibility, but also policies and procedures.

## [Physical Access]{.underline}

The center proposed repairs/replacements for curb cuts and sidewalks
totaling \$200,000. The work was completed

## [Service Improvement]{.underline}

CCCIL was a member of the Salinas ADA Ad-Hoc Committee that assisted in
establishing the ADA Transition Plan for the City of Salinas. CCCIL's
successful efforts included: modifications to be made to Steinbeck
Public Library which became compliant with the ADA in July, 2000; the
establishment of accessible emergency call boxes on highway 101; new
curb cuts in the cities of Pacific Grove, Seaside and Salinas;
Paratransit services to South Monterey county, the most rural part of
our community and; the establishment of a transportation task force
which is focusing on developing methods if improving current Paratransit
services, to name a few.

## [Service Maintenance]{.underline}

Our center succeeded in advocacy efforts to upgrade Hall County Park.
There is now a new accessible unisex restroom, a new accessible drinking
fountain, two new accessible parking lots, new accessible routes, and
new signage all over the park directing the public to the accessible
features. Plans have also been made for two additional new accessible
restrooms.

## EMPLOYMENT

**[Communication Access]{.underline}**

Advocacy was done at the US Censor Bureau, WITH Mr. Chuck Reilly to
provide a temporary TTY phone line for consumers to call for job
placement.

## 

## [Legislation]{.underline}

ABIL mobilized consumers locally and nationally to advocate for the
successful passage of the Ticket to Work and Work Incentives Improvement
Act of 1999 which will remove many of the current barriers to employment
for people with disabilities. ABIL's Executive Director at that time,
Susan Webb, traveled to Washington D.C. to testify before Congress on
the need for TWWIIA and educated people across our state on its
contents.

**[Physical Access]{.underline}**

Lobbied for move of not fully accessible Middleton career center and in
FY'01 this career center will be moved to a fully accessible site in
Salem.

## [Policy]{.underline}

RCIL has been involved in system change initiatives in the employment
area. As a member of the Workforce Investment Board, RCIL has been very
involved in the establishment of the One Stop Service Centers, four of
which will be located in the three county area. RCIL has made specific
recommendations to make all sites totally accessible. This includes
recommendations for technology. RCIL drafted a diversity statement for
the selection of staff and general access issues. This was incorporated
into the overall policy of the One Stop overseen by the Workforce
Investment Board and is now being replicated by other Workforce
Investment Boards in the state. RCIL's involvement resulted in training,
activities, services and products, designed to comply with the mandates
of the ADA, Section 504 of the Rehabilitation Act, the Workforce
Investment Act (WIA), and the NYS Department of Labor.

## [Service Improvement]{.underline}

At the request of a consumer, Staff contacted the Blood Services
Division of the American Red Cross regarding difficulties that persons
with disabilities had after being placed there by a state vocational
rehabilitation agency. Consumers reported being threatened by staff
about bringing a service animal into the workplace, and difficulties in
providing reasonable accommodation with regard to scheduling and other
policies. Staff spoke to the head of the local blood services division,
and discussed the issue. It was agreed that training and technical
support were needed, as the persons placed, and others projected to be
placed, constituted a valuable asset to the Red Cross work force.

# TRANSPORTATION

## 

## [Legislation]{.underline}

We worked toward successful passage of HB 4995. In our efforts to
support this bill, we provided oral testimony to the House
Transportation Committee and written testimony to the Senate
Transportation Committee. The bill is now law and makes it illegal to
park in the access aisles adjacent to accessible parking spaces or in
front of curb cuts.

## [Physical Access]{.underline}

ECNV also assisted the process for WMATA's proposed changes to the
Pentagon Metro station that resulted in making the renovation
construction plan be more accessible.

## [Policy]{.underline}

The CIL serves on a committee worked on the Taxi Cab ordinance (for the
first time in Charlotte history) that will include a section on private
vehicles that transport individuals who use wheelchairs.

**[Service Improvement]{.underline}**

The Columbia Transit Service announced plans for purchasing new lift
equipped buses and installing 30 benches and five (5) shelters along
Columbia bus routes. The City of Columbia also began making improvements
to downtown sidewalks as recommended by the Disabilities Commission.
Board Members Lee Henson, Christy Welliver, Kathleen Weinschenck and
staff member Jerry Morris serve on the commission.

## [Service Maintenance]{.underline}

BILC advocated for improved transportation services for people with
disabilities, including compliance with ADA requirements. The center
staff and consumers participated in public meetings regarding
transportation issues, including the transit system advisory committee.
The Center organized a May, 2000 March to City Hall in support of City
funding for public transportation. Despite cuts in funding for fixed
route transit, the City Council maintained funding for evening and
weekend paratransit services.

## OTHER ACTIVITIES

## [Communication Access]{.underline}

For the past 5 years, SAIL has attempted to have the Alaska equivalent
of C-span, Gavel to Gavel, close-captioned for the deaf/hard of hearing
community. The effort is finally bearing fruit, and the local PBS
television station is seeking financial sponsors to accomplish this.
This would affect a statewide audience.

## [Legislation]{.underline}

OIL assisted in the drive to establish an Oklahoma State Independent
Living Act. OIL served as an education tool to bring about awareness and
understanding of the Act. The Act mirrored federal law and regulations.
The IL Act was adopted into Oklahoma law.

## [Physical Access]{.underline}

ILR continued through this year to house the local ADAPT Chapter as part
of the center's commitment to advancing community advocacy locally and
nationally. A number of victories in this arena were won due to these
efforts this past year. A recent effort by ADAPT occurred this past
summer when NIKE introduced a controversial ad that was devastating for
the disabled. ADAPT arranged for a national apology and is currently
working on ensuring that NIKE and their advertising agents receive
disability awareness training. This is still a work in progress

## 

## [Policy]{.underline}

The Consumer Advocacy Committee brought A+ Links and the Supervisor of
Elections together in order to set up a voter registration system in
which the A+ Links drivers were required to inquire if paratransit
riders are registered voters. If the riders were not already registered,
the driver provides the necessary voter registration forms to enable the
rider to register to vote.

## [Service Maintenance]{.underline}

In October, 1999 the center lead a coalition that sponsored a candidates
forum for the Mayor's race (of Birmingham). All major candidates
participated, including the winner. Over 100 people attended. Candidates
were asked their position on various disability issues and responded to
questions posed by the audience. BILC staff and board met with the new
mayor to advocate for the re-vitalization of the Mayor's advisory
committee on disability issues, hiring a liaison to the disability
community, and other issues. Names were submitted to the Mayor to fill
the liaison position.

## [Service Improvement]{.underline}

1\. The ILRC was instrumental in the establishment of a Disability
Awareness Task force made up of representatives from the entire City
Training Divisions for the purpose of training not only the Sheriff's
department, but the Jail staff, fire and rescue etc.

2\. During the 1999-2000 Program Year, the Independent Living Resource
joined the California Foundation of Independent Living Centers to
advocate for a budgetary augmentation through the state to establish
assistive technology components within centers. This effort was
successful and each center received \$75,000 for this purpose. In this
context, the term \"assistive technology\" (AT), is broad in scope and
encompasses any equipment, devices, assistance, or structural
modifications that enhance the independence of people with disabilities.

**APPENDIX F**

**INSTRUCTIONS FOR CENTERS ON SELECTING CONSUMERS**

Appendix F

Dear\_\_\_\_\_\_\_\_\_\_\_\_\_\_:

The Rehabilitation Services Administration (RSA), in the Office of
Special Education and Rehabilitation Services (OSERS), U.S. Department
of Education, has funded a comprehensive two-year evaluation of Parts B
and C of the Centers for Independent Living (CIL) program. Cherry
Engineering Support Services, Inc. is under contract with RSA to conduct
the study. This evaluation will include a survey of executive directors
of all federally funded CILs and a telephone survey of a nationally
representative sample of current and former consumers of CIL services.
The surveys will evaluate outcomes of community advocacy and center
services, as well as consumer satisfaction. In late January, you
received a letter from Judy Heumann, Assistant Secretary of OSERS,
telling you about this study and requesting your cooperation.

You will receive the survey of executive directors under separate cover.
In addition to filling out the executive director survey, your center
has been randomly selected to participate in the consumer survey.
Information about the consumer survey and instructions for selecting
respondents are enclosed.

As a subcontractor to CESSI, Westat is responsible for conducting all
operations related to the administration of the consumer questionnaire.
Because we recognize that CIL consumer information is confidential, we
are asking for your assistance in recruiting respondents for the survey.

The enclosed Sampling Instructions describe the steps you will need to
take to select consumers for the survey. We want you to select consumers
who are currently receiving services from your CIL as well as those who
have stopped receiving services within the last six months. The Consumer
Contact Steps and Information are based on Westat's extensive experience
recruiting survey participants. However, since you are familiar with
your consumers, please feel free to tailor the scripts to your
situation. You will be working with Jean Wilson from Westat to complete
this procedure. If you have any questions, you may call her at
1-800-937-8282 EXT. 2836

Westat will only contact consumers who have agreed to participate in the
survey. It is important for you to encourage those selected to be in the
survey and to let them know that their input is very important. The
information they provide will be used to determine consumer satisfaction
with the CILs. All of their responses will be completely confidential
and will not be linked with your CIL. If you have any questions, please
contact me at (703) 845-3436. On behalf of the Rehabilitation Services
Administration, Department of Education, CESSI and Westat, I would like
to thank you for your assistance in this project. Your help is
invaluable for the completion of this study.

Sincerely yours,

Bonnie O'Day

Senior Research Associate

CESSI

Evaluation of Independent Living Centers

About the Study: The U.S. Department of Education's Rehabilitation
Services Administration is conducting a study to describe the activities
and services of Centers for Independent Living, how Centers help people
with disabilities, and how satisfied consumers are with the services
they receive. Your Center was selected as part of a representative
sample of all Independent Living programs in the United States, and your
participation is essential for the success of this study. We are looking
forward to working with you and are committed to making this as
efficient and effective an effort as possible.

What we are asking you to do?

**A staff member from Westat will be contacting you within the next
several days to go over your participation in this important study.** We
will be reviewing the packet of materials; so please have the enclosed
information available when we call.

It would also be helpful if you are able to complete the following step
prior to our call:

1)  **You will need to have a numbered list of consumers**: This list
    should consist of consumers who have received services within the
    last six months (whether their cases are open or closed). If you
    have several lists of consumers, e.g., open and closed cases, we
    just need to know the total number of consumers who have received
    services within the last six months across all the lists.

**Once you have prepared the list of consumers,**

2)  **If you would like to, you may** **go ahead and** **call Jean
    Wilson at Westat**. Her telephone number is 1-800-937-8281
    EXT. 2836. Tell Jean how many consumers are on the list.

3)  **Jean Wilson will put that information into her computer**. The
    computer will select 15 consumers from your list by giving you line
    numbers to match with consumers on your list. These line numbers
    tell us which 15 numbered consumers have been selected for the
    survey.

The remaining material in this packet covers activities that will occur
after selecting the consumer sample from your list(s). We will be going
over these steps when we call and can answer any questions you may have.

**Evaluation of Independent Living Centers**

######## Consumer Contact Steps and Information 

Steps for Contacting Consumers

These instructions identify how we would like you to contact consumers
to be part of the survey for the Evaluation of Independent Living
Programs.

The following steps are needed to complete the contacting of Center for
Independent Living Consumers for the Survey:

1)  **You will contact the consumers Jean has asked you to contact**.
    The information you need to know to contact the consumers for the
    study is given in the **Consumer Contact Steps and Information**.
    Please complete this process by June 29, 2001. If you are not able
    to reach the consumers at the telephone number they gave you, please
    try to reach them through other contact information you may have in
    their file.

2)  **If you are unable to reach a consumer by telephone (either theirs
    or another contact's telephone number), mail them one of the
    enclosed postcards**. Be sure you fill in the name of the consumer,
    sign it, and fill in the name of your CIL as well.

3)  **Do not substitute one consumer for another**. If you are not able
    to reach a consumer or have them agree to participate in the study,
    tell us that. We need to know how many of the selected consumers
    agreed to participate and how many were not contacted or refused to
    participate for statistical purposes. We do not need the names and
    telephone numbers of consumers who refuse to participate or who can
    not be reached.

4)  **Once you have contacted the consumer and secured permission from
    them, you will give Jean the information from the attached "Tracking
    Calls for Scheduled Interviews" form for each consumer who agrees to
    be part of the study**: name, address, telephone number, best time
    to contact the consumer, and any accommodations they will need to
    complete the survey. Please contact Jean no later than July 6, 2001.

5)  **If they have an interpreter they usually use, or want us to
    interview a proxy, be sure to get that person's name and telephone
    number.** We would prefer to interview the consumer, rather than a
    proxy, if at all possible. Although proxies will not be paid for
    their participation, interpreters/translators will be paid \$50 for
    their time. Please advise consumers and/or any interpreters or
    translators you speak with that \$50 is the only amount we will pay
    for the translator's/interpreter's participation in the survey.

6)  **Please call Jean with this information. We also need you to send
    the completed form to us.** You may send this file to Jean via email
    (<WILSONJ1@westat.com>), via fax (301-294-2829 or 301-610-5128) or
    by mail in the enclosed envelope:

> Jean Wilson
>
> 1650 Research Blvd
>
> RP 4027
>
> Rockville, MD 20850.

7)  **Westat will then contact these consumers and conduct the
    interview**. *Each consumer who completes the survey will receive
    \$10 as a thank-you gift for participating.*

Consumer Contact Information

Suggestions for Contacting Consumers

-   Make a minimum of four attempts to reach the consumer (different
    times in the day and different days of the week). Some people can
    only be reached on the weekends. Other people may need a postcard
    mailed to them, and they will contact you. *The attached grid will
    help you keep track of the calls and when the scheduled interviews
    will take place.*

-   Explain the purpose of the study.

-   Emphasize that this is a phone interview, but if an interpreter is
    needed, we can accommodate the interpreter's schedule.

-   If necessary, we can mail the questionnaire, but this is only as a
    last resort. The questionnaire is designed to be a telephone
    interview.

Talking Points

-   The survey will take only 30 minutes.

-   All information gathered will be strictly confidential, and no
    identifying information will be released.

-   The survey is being conducted by Westat, a research firm in
    Maryland, contracted by the Rehabilitation Services Agency,
    Department of Education.

-   It should be pointed out that they (the consumer) will be assisting
    RSA and Westat in the gathering of information on consumer
    satisfaction with services they receive from CILs. However, their
    responses will NOT be associated with their CIL. It is a survey of
    consumers from many CILs. We are offering \$10 for their
    participation.

######## Who Can Be A Proxy

The proxy should live with the consumer or spend most of their time
caring for the consumer on a daily basis. A proxy should be able to
answer questions for the consumer as if they were the consumer. Tell the
proxy the questions will ask about the consumer's experiences with the
Center; the consumer's satisfaction with the services they received from
the Center, plus questions about the consumer's life in general. If the
proxy does not feel comfortable answering those kinds of questions for
the consumer, then another proxy needs to be designated. A proxy can be
the consumer's:

Caretaker

Spouse

Adult Child

Sibling

Anyone else who knows the consumer really well and who has been
designated by the consumer as a proxy.

A proxy will not be paid for their participation in the survey.
Employees of the CIL can not act as proxies for this questionnaire.

**Who Can Be Interpreters/Translators**

The interpreter can be the consumer's:

Caretaker

Spouse

Child aged 14 or older

Sibling

Anyone else who has been designated by the consumer as an interpreter.

The interpreter can also be a paid professional interpreter/translator.

Anyone who acts as an interpreter/translator will be paid \$50.

Remember: We can administer the questionnaire directly to the consumer
in Spanish. Therefore, Spanish speaking consumers should not need an
interpreter.

Employees of the CIL can not act as interpreters/translators for this
study.

Suggested Script

*Good Morning (afternoon), may I please speak with
\_\_\_\_\_\_\_\_\_\_\_\_(*name of consumer*)?* (If they are not at home,
find out when a good time would be to call them back.)

> OR

*Good Morning (afternoon)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(*consumer's
name*). My name is* \_\_\_\_\_\_\_\_\_\_(your name*). I am calling from
\_\_\_\_\_\_\_\_\_\_(*name of CIL*) to ask you to participate in an
important study sponsored by the Rehabilitation Services Administration
of the U.S. Dept. of Education. With your permission, a representative
from Westat, a research firm hired to conduct the study, will be calling
you to conduct the interview. The survey will take approximately 30
minutes. Your answers to the questions will be kept confidential and
will be used only for the purpose of this study. You will be given \$10
for your efforts. May I give your name, address, and telephone number to
Westat so that you can be part of this study?*

**Evaluation of Independent Living Centers**

**Consumer Contact Materials**

+---------+---+----+---+---+--------+-----------+-------+-------------+
| ####    | * | ** | * | * | **O    | **Address | *     | **ACC       |
| #### Na | * | Ar | * | * | utcome | of        | *Best | OMMODATIONS |
| me of C | D | ea | D | T | of     | C         | Da    | if needed   |
| onsumer | a | C  | a | i | Phone  | onsumer** | ys/Ti | (           |
|         | t | od | y | m | Call   |           | mes** | interpreter |
|         | e | e/ | o | e | If     | **House   |       | name and    |
|         | o | P  | f | * | tel    | Number,   | **for | telephone   |
|         | f | ho | * | * | ephone | Street,   | I     | number/     |
|         | B | ne | * |   | discon | Apt \#**  | nterv | proxy name  |
|         | i | N  |   | * | nected |           | iew** | and         |
|         | r | o. | * | * | or     | **City,   |       | telephone   |
|         | t | ** | * | C | co     | State,    | **(DO | number) or  |
|         | h |    | C | a | nsumer | Zip       | NOT   | Comments**  |
|         | * |    | a | l | no     | Code**    | SCH   |             |
|         | * |    | l | l | longer |           | EDULE |             |
|         |   |    | l | e | at     |           | A     |             |
|         |   |    | * | d | that   |           | SPE   |             |
|         |   |    | * | * | tel    |           | CIFIC |             |
|         |   |    |   | * | ephone |           | TI    |             |
|         |   |    |   |   | n      |           | ME)** |             |
|         |   |    |   |   | umber, |           |       |             |
|         |   |    |   |   | send   |           |       |             |
|         |   |    |   |   | postc  |           |       |             |
|         |   |    |   |   | ard.** |           |       |             |
+---------+---+----+---+---+--------+-----------+-------+-------------+
| *E      | * | *3 | * | * | *Co    | *14       | *     | *Caregiver  |
| xample: | 8 | 01 | W | 1 | nsumer | Windmill  | After | answered;   |
| Mary    | / | -6 | e | 1 | not    | Road*     | 6     | will speak  |
| Brown*  | 8 | 41 | d | : | in*    |           | :00PM | with        |
|         | / | -1 | . | 0 |        |           | Mon,  | consumer*   |
|         | 5 | 12 | * | 0 |        |           | Wed,  |             |
|         | 5 | 1* |   | A |        |           | Fri*  |             |
|         | * |    |   | M |        |           |       |             |
|         |   |    |   | * |        |           |       |             |
+---------+---+----+---+---+--------+-----------+-------+-------------+
|         |   |    |   |   |        | *Silver   |       | *on return  |
|         |   |    |   |   |        | Spring,   |       | to see if   |
|         |   |    |   |   |        | MD 20902* |       | she is      |
|         |   |    |   |   |        |           |       | willing to  |
|         |   |    |   |   |        |           |       | do          |
|         |   |    |   |   |        |           |       | interview*  |
+---------+---+----+---+---+--------+-----------+-------+-------------+
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+---------+---+----+---+---+--------+-----------+-------+-------------+
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+---------+---+----+---+---+--------+-----------+-------+-------------+
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+---------+---+----+---+---+--------+-----------+-------+-------------+
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|         |   |    |   |   |  sent: |           |       |             |
+---------+---+----+---+---+--------+-----------+-------+-------------+
|         |   |    |   |   |        |           |       |             |
+---------+---+----+---+---+--------+-----------+-------+-------------+
| **Name  | * | ** | * | * | **O    | **Address | *     | **ACC       |
| of      | * | Ar | * | * | utcome | of        | *Best | OMMODATIONS |
| Con     | D | ea | D | T | of     | C         | Da    | if needed   |
| sumer** | a | C  | a | i | Phone  | onsumer** | ys/Ti | (           |
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|         | e | e/ | o | e |        |           |       | name and    |
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|         | f | ho | * | * |        |           | I     | number/     |
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|         | * |    | l | l |        |           | EDULE |             |
|         |   |    | l | e |        |           | A     |             |
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|         |   |    |   | * |        |           | TI    |             |
|         |   |    |   |   |        |           | ME)** |             |
+---------+---+----+---+---+--------+-----------+-------+-------------+
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+---------+---+----+---+---+--------+-----------+-------+-------------+
|         |   |    |   |   | **Date |           |       |             |
|         |   |    |   |   | po     |           |       |             |
|         |   |    |   |   | stcard |           |       |             |
|         |   |    |   |   | s      |           |       |             |
|         |   |    |   |   | ent:** |           |       |             |
+---------+---+----+---+---+--------+-----------+-------+-------------+

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of Center

Dear \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

We were looking at some of our consumer records and were unable to reach
you when we tried to call. Please contact us as soon as possible. We
would like to update our records with your current information.

We would also like to speak with you about being part of a national
evaluation of centers for independent living. If you agree to be part of
this evaluation and are selected to be interviewed, you will be paid
\$10 and will only need to complete a 30 minute telephone questionnaire.
If you need an interpreter/translator, that person will also be
reimbursed for their time as well.

Sincerely,

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_