Survey - Open Doors Initiative

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Part 1 CoHabit Neighbour Demographic Survey

Select one

I am a family member/caregiver, or other advocate filling out this survey on behalf of a potential CoHabit Neighbour

I am a potential CoHabit Neighbour

Clear selection

What is your Health Condition/Disability? (Select all that apply)

Cerebral Palsy

Multiple Scelerosis

Acquired Brain Injury

Autism Spectrum Disorder

Stroke

Muscular Dystophy

Fibromyalgia

Blind

Visual Impairment

Deaf

Hard of Hearing

Intellectual Disability

Mental Health Illness

Other:

How old are you?

17 or under,

18-20,

21-29,

30-39,

40-49,

50-59,

60-64,

65+

Clear selection

What is your primary/preferred language?

English

French

Other:

Clear selection

Please select your preferred method of communication. Select all that apply:

Speaking

ASL

Augmentative and Alternative Communication (AAC) Device with pictures or typing with speech output

Using individualized signs and/or gestures

Other:

Do you Identify with one or more minority communities?

Yes

Prefer not to answer.

Clear selection

If yes, please select a minority population you represent (select all that apply)

Disability

First Nations - non-status

First Nations - status

Metis

Inuit

Asian

Hispanic

Black

Gender Minority

Other:

Do you currently receive financial support from Community Living disABILITY Services (CLDS)?

Yes

I don't know

Clear selection

What is your current living situation?

Live with parents/family

live on your own

live with a roomate or partner

live in a personal care home

live in a group home

Other:

Clear selection

Are you currently employed? If yes, how many hours per week?

No, currently unemployed

Yes, 1-9 hours/week

Yes, 10-19 hours/week

Yes, 20-29 hours/week

Yes 30-40 hours/week

Clear selection

If you are currently unemployed, would you be interested in gaining a job?

Yes, desired part time (less than 20 hours/week)

Yes, desired full time (more than 30 hours/week

Clear selection

What type of mobility aid do you currently use? (Select all that apply)

Cane(s)

Walker

Power wheelchair

Manual Wheelchair

Electric scooter

N/A

Other:

What personal self-care equipment do you require? (Select all that apply)

Commode chair

Grab bars

Hoyer lift

Sit to stand lift

N/A

Other:

Clear form

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