PADDC Satisfaction Survey - SDMPA

Supported Decision Making Pennsylvania

Please check categories below that describe identify yourself.

Note: This data is being requested by our federal funder. Please provide the information for their records. This will not impact services or trainings provided.

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* 1. Project Activity/Event

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* 2. Date

Date

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* 3. Please identify who you are:

Individual with a developmental disability

Family Member

Other (please specify)

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* 4. Please check all categories below that describe how you identify yourself.

White, alone

American Indian or Alaska Native alone

Asian alone

Black or African American alone

Hispanic/Latino

Native Hawaiian & other Pacific Islander alone

Race Unknown

Prefer not to answer

Two or more races or Self Identify

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* 5. What is your current gender?

Man

Woman

Non-Binary

Two Spirit (*If American Indian or Alaska Native)

Prefer not to answer.

I use a different term. (write in)

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* 6. Do you consider yourself to be transgender?

Yes

Prefer not to answer.

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* 7. Which of the following best represents how you think of yourself?

Lesbian or Gay

Straight, that is, not Gay or Lesbian

Bisexual

Two Spirit (*If American Indian or Alaska Native)

Don't know

Prefer not to answer.

I use a different term (write in)

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* 8. Which best describes the area you live in?

Rural

Urban

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* 9. Which county do you live in?

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* 10. I (or my family member) can speak up for myself better because of what we did today.

Yes

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* 11. I (or my family member) can say what I want better, or what is important to me because of what we did today?

Yes

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* 12. I (or my family member) take part in advocacy events.

Yes

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* 13. I (or my family member) take part in cross disability coalitions, policy boards, advisory boards,decision-making groups: or I am the leader of a group.

Yes

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* 14. I (or my family member) am satisfied with what we did today.

Yes