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Survey

Please take a moment to fill out the following survey.  Your input will help us improve our site.  If you have limited time, please answer questions 1 and 2 and then scroll to the bottom and answer question 13.
Click HERE for extended Survey

1.  Are you affiliated with (i.e., employed by or receiving services from):

   The Massachusetts Department of Mental Retardation

   Another mental retardation association

   Not affiliated with any mental retardation association

2.  Are  you a: 

        Parent     Service Provider     Therapist     Consumer

  Other:

3.  If Therapist: (Please check all appropriate.) 

  Occupational Therapist 

   Physical Therapist   Speech Therapist
  Recreational Therapist   Psychologist   Music Therapist
  Other:  

4.  If Service Provider: (Please check all appropriate.)

  Educator 

   Service Coordinator   Vocational Instructor
  Social Worker   Personal Care Provider  
  Other:  

5.  Diagnoses of Consumer(s): (Please check all appropriate.) 

  Mental Retardation 

   Autism/P.D.D.   Down Syndrome
  Speech/Language Disorder   Seizure Disorder   Visually Impaired
  Attention Deficit Disorder   Hearing Impaired   Acquired Brain Injury
  Cerebral Palsy  Other:

6.  Functional Limitations of Consumer(s): (Please check all appropriate.) 

  Vision 

   Memory/Organization   Mobility/Balance
  Hearing   Reaching/Lifting   Hand Use
  Speech   Other:

7.  Age of Consumer(s):

    0-10 Years   11-22 Years   23-55 Years     55+ Years

8.  Current Living Situation of Consumer(s): 

   Independent

   Community Residence (State operated)
   With Family   Community Residence
        (Privately operated)
   Nursing Home   State Institution
Other:

9.  Day/Work Education Program of Consumer(s):

  Habilitation/Leisure Program

   Supported Employment
  School/Special Education   Sheltered Workshop
  No Day/Work Program   Competitively Employed
Other:  

10.  How did you find out about this web site?  

  Adapted Activities Library Brochure

   Referred by Service Provider
  Another Web Site   Word of Mouth
  Web Search Other:

11.  What activities/products are you looking for?  (Please check all appropriate.) 

    Environmental Control 

     Communication   Computer Use
    Sensory Stimulation

    Cooking

   Recreation
    Self Care     Work Aids   Memory Aids
Other:

12.  Are you interested in purchasing any products described on this web site?  

  Yes   Maybe
   No If not, why not?  (Please check all appropriate.)
Didn't find what I needed
Not enough info to decide		 Didn't see anything new
 Other: 

13.  Did you find any information that you plan to use or to pass on to someone else?

Yes      No

 

Optional:  Tell us how to get in touch with you:

First Name:
Last Name:
E-mail:
Tel:
FAX:
City:
State
Country:

      

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