Needs Questionnaire (print, fill-in and mail)

We are interested in hearing from you. Whether you are a survivor, family member, professional, provider, or an interested supporter, your input is greatly appreciated.

Please take a few moments to answer the questions below and return the form to our office. Answer only the questions you feel comfortable with.

All information provided will be kept confidential. No identifying information will be released

Are you a:

__ Survivor

__ Parent or Family member

__ Caregiver

__ Professional

Other _________________________

What is your marital status

__ Single __ Married

__ Divorced __ Separated

__ Widowed

What is your ethnic background?

__ Caucasian

__ Hispanic

__ African American

__ Asian American

__ Native American

__ Multiracial

How many years of education have you completed?

__ Less than 12

__ High school graduate

__ Some college

__ College graduate

Are you:

__ Male    __ Female

What is your age group?

__ Under 21 years

__ 21 – 30 years

__ 31 – 40 years

__ 41 – 50 years

__ 51 – 60 years

__ 61+ years

What is your employment status?

__ Paid work full-time

__ Paid work part-time

__ Student

__ Not working

__ Retired

__ Unpaid volunteer work

Medical insurance coverage is provided through:

__ Auto no-fault

__ Family health insurance coverage

__ Medicaid

__ Medicare

__ No coverage

What city/town do you live in? _________________________________

 

What county do you live in? ____________________________

What is your zip code? _____________________

Are you a current member of the Brain Injury Association of West Virginia?

__ Yes. For how many years? ____________

__ No. Have you ever been a member? __  Yes   __ No

What is your current level of involvement with a local support group?

__ Actively involved (specify which group): ______________________________

__ Not actively involved

__ Would be involved if there was a support group in my area

__ Other (please describe): _________________________________________

What is your current level of involvement with the BIA-WV (check all that apply)

__ Current board member

__ Past board member

__ State conference attendee

__ Volunteer

__ No involvement

__ Other (specify): ________________________________________________

Where have you sought and/or received services/assistance (check all that apply)

__ Medical outpatient services

__ Non-hospital based rehabilitation providers

__ Hospital based rehabilitation providers

__ WV Division of Rehabilitation Services (WVDRS)

__ Department of Health and Human Resources (DHHR)

__ Community Mental Health services (i.e., mental health, substance abuse services)

__ Center for Independent Living

__ Local school district

__ WV Assistive Technology Services (WVATS)

__ Out of state services (what state(s)): _______________________________

__ Other (specify): _______________________________________________

Please feel free to describe any problems or successes you have had with any of the above programs.

Please check any item(s) below that are important to you. Also indicate whether each item is a problem or if the need is met.

 

Topic Important Problem Need Met?
a. Barrier-free housing      
b. Independent living      
c. Public transportation      
d. Long-term medical concerns      
e. Access to adequate medical care      
f. Financial planning      
g. Job planning and employment      
h. Educational/vocational opportunities      
i. Long-term supported living      

Please check whether you agree with each statement below.

Statement Agree Disagree Not Sure
a. BIA-WV should expand advocacy efforts on behalf of people with a TBI.      
b. BIA-WV should expand prevention efforts.      
c. Regional educational programs and conferences would increase awareness throughout the state.      
d. BIA-WV should provide more educational programs throughout the state.      
e. BIA-WV should offer direct services to members.      
f. BIA-WV should partner with other programs to increase our prevention and education efforts.      

Membership in BIA-WV is an important way to ensure that BIA-WV can meet your needs now and in the future. Would you like us to send you a membership application?

__ Yes (if Yes, please give is your contact information)

Name: ____________________________________________________________

Address: __________________________________________________________
                        (Street /City/ State/ Zip)

Phone ______________________ Email: _________________________________

__ No

You may also Click Here for a Printable Membership Application

Your comments are as important as your responses to the above questions. Please feel free to use this space (and additional pages) to tell us what you need from BIA-WV, how you want to be involved, you personal story, etc.

Thank you for completing this questionnaire. Please return it to BIA-WV my mail, e-mail or fax.

Mail: BIA-WV  |  PO Box 574  |   Institute, WV 25112-0574
E-mail: biawv@aol.com   Fax: 304-766-4940

If you would like to talk with someone personally about your concerns, needs, or ideas please feel free to call our helpline at 1-800-356-6443 and leave a message. Your call will be returned promptly.