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2006 Needs Assessment Survey

Every three years, the Jefferson Area Disability Board (DSB)assesses the needs of people with physical and sensory disabilities
in the Thomas Jefferson Planning District (the City of Charlottesville and the Counties of Albemarle, Fluvanna, Greene, Louisa and Nelson).

This information is used to:

  • Guide the activities of the DSB
  • Inform local officials of needs within their jurisdictions
  • Advise state agencies

If you feel you have a physical and/or sensory disability, please take the time to fill out the following questions.
You may also fill out the survey for a friend or family member. This survey is also available as a downloadable pdf file (31 KB)

Demographic Data

Year of Birth: Gender: M  F

Highest Level of Education:

I live in: Albemarle  Charlottesville  Fluvanna  Greene  Louisa  Nelson

Employment Status: Part-Time  Full-Time  Retired  Unemployed  Student  Volunteer  Looking for a job

Current Living Arrangement: Own house/apt/condo  Rent  Group Home  Nursing Home  Parent/Relative/Friend  Homeless  Other:

Type of Disability:

(check all that apply)
Blind / Vision Impaired:
Deaf / Hard of Hearing:
Speech Impaired:
Physically Disabled:
Brain Injury:
Other (Autism, Aspergers Syndrome, Chronic Medical, etc.) Describe:

Future Goals

What do you want to achieve in your future?

What barriers might keep you from reaching your goals?

What do you need to reach your goals?

Please share any other thoughts you have about the needs of people with physical, visual or hearing
disabilities and available services in our region. Feel free to attach another sheet if you need more space.

Please Check all that apply

Services
Service is:
I have an unmet need for this service and it affects me:
Comments
 
OK
Not OK
needed but not available
needed but too costly
Seriously
Moderately
Slightly
  

Assistive Technology

Adaptive equipment-wheelchairs/visual aids/computers

Case Management

Coordinate programs and services

Counseling

Social workers, psychiatrists, rehab counselors

Education

Early intervention to high school for youth with disabilities

Employment Services

Job preparation and job placement

Family Support Services

Counseling/case management to support family members

Accessible Housing

Accessed without physical barriers

Independent Living Services

As through Centers for Independent Living

Medical & Therapeutic Services

Accessible and affordable medical insurance & Services

Personal Assistance Services

Help with daily living activities like cooking or household management

Training

For employment or upgrading skills

Transportation

Available and accessible for persons with disabilities



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