Needs Questionnaire for Persons with Spinal Cord Injuries

The purpose of the questionnaire is to gather data detailing the needs of people with spinal cord injury in the State of Illinois. All questions concern people paralyzed, regardless of the cause. Throughout the questionnaire, ‘you’ refers to persons with a Spinal Cord Injury.

If someone other than the injured person is completing this form, please indicate the relationship:

Gender:    Male    Female    Present age Age when injured

What is the level of your injury?

What was the cause of injury?

What is your Race or Ethnicity?

Where do you live?  Private Residence ( Own    Rent)   Subsidized housing   Group home/Transitional living facility     Nursing home/Long term care facility 

Other (please describe:

Who lives with you? (Check all that apply)    Alone   Spouse/Partner   Siblings   Parent (s)
Children under age 21   Children 21 and over       Personal Care Attendant/Aide         
Friends/roommates       Other (please describe:          

Are you married? Yes    No  Were you separated or divorced after injury?  Yes   No

What is your education level?     Less than high school    GED/High School    Bachelors    Advanced Degree

Were you a student at the time of injury?     No     Part-time      Full-time

Were you employed at the time of injury?    No     Part-time      Full-time        

Were you able to go back to your former employer?    Yes     No         

Are you presently employed?  Yes     No          Have you tried to find employment?          Yes    No 

Please tell us about assistance you received in the past or may now need:

Did you receive adequate information about support services immediately following injury?     Yes   No

Who was your best source of information about rights or benefits when you were newly injured?
Doctor     Nursing Staff     Physical Therapist        Occupational Therapist      Social Worker
Family/Friend      Other Patients      Other-Explain (State Agencies, etc.)

Do you currently have adequate access to information about support services?                Yes   No

Where do you currently go for information, including health questions? (check all that apply
Rehabilitation Doctor    Family Doctor’s Office    Visiting Nurse   Home Health Aide   Family    Friend
Rehabilitation Social Worker   Physical Therapist      Occupational Therapist    DME Vendor
State Rehabilitation Counselor    Community Health Dept.    Center for Independent Living
Spinal Cord Injury Association    Internet   Other

Would you attend a support group if it were near your home?   Yes   No

If you reside in a nursing home, group home or transitional living facility and want to live independently/outside of a facility, what would you need to do so. Please check all that apply:

Attendant Care    Financial Assistance    Transportation     Assistive Technology   Accessible Home/Apartment Live close to family/friends   

Other:

What state agencies are currently providing you with assistance or guidance?  Briefly describe service.

What are currently the greatest problems related to your disability?
What is your zip code?

Thank you for your time and effort.
Please return the questionnaire to the address or email address listed below.
A copy will be on our website,  www.sci-illinois.org, should you wish to forward it to anyone you feel will help us acquire this important information.
If you have any further questions or comments, please contact:
Spinal Cord Injury Association of Illinois
 1032 S LaGrange Road
LaGrange, IL 60525
(708) 352-6223  Fax: (708) 352-9065 SCIinjury@aol.com
This project is made possible by a grant from the Illinois Department of Public Health