Attention, people with disabilities who live in Maine! This survey is an important feedback tool for you. You are free to answer questions of your choice and skip those you do not choose to answer. Information gathered by this survey will be used as input while creating the three year state plan for independent living required by the Federal Department of Education’s Rehabilitation Services Administration. The Maine SILC will also use this information for its advocacy and outreach efforts. This is an informal survey created by the Maine Statewide Independent Living Council and names, street addresses, and personal information will not be connected with the results. The survey is set up in three sections. Each section gives us a separate result page so your information will be delivered to us as you complete it. The survey results are meant to reflect a cross section of opinions of individuals with disabilities in Maine. The Maine Silc encourages you to join us in our work

1. Answers provided in this section give us some idea of your personal and family status and location in Maine. Town where you live:

Your age:

Your race or ethnicity:

Your gender :

Marital and family status:



2. Please check the one item which best describes your housing situation?

Choose One I live alone I live along with in-home supports. I am a youth living with my family. I live with my family. I live with a room mate. I live with friends. I live in a boarding home. I live in a nursing home. I am currently homeless.


3. Please indicate the nature of your disability: Choose One Cognitive Mental / Emotional Physical Hearing Vision Multiple Other


4. The next two questions are to determine what services you receive. Are you currently receiving any of the following SERVICES? Check all that apply.

Subsidized Housing
Residential coordinator services
Housing modifications
Assistive Technology services
Education Services
Youth/Transitional services
Communication Services
Mental Health Services
Independent Living Services
Elder services


5. Are you currently receiving any of the additional following services? Check all that apply. University or college disability services
Advocacy / Legal Services
Personal Assistance services
Life Skills Training
Mobility Training
Special education Services
Vocational rehabilitation Services
Technology Services
Dayhabilitation services
transportation Services


6. Are you still waiting to receive any services that you have asked about and qualified for? If so, please indicate what they are.


7. If you have any difficulty with mobility inside or outside your home, please describe the difficulty and tell us what would be helpful to make things easier.


8. Do you have telephone service? Check all that apply.
I have a wired phone in my home
I have a cell phone
I use a “community phone” where I live
I use a friend’s phone
I use a pay phone.
to use a phone I need special equipment that I do not have
I do not use a phone


9. The following lists transportation possibilities. Please check any statement that applies to you.

I own and drive a vehicle.
I own a vehicle but can not drive.
I can drive but I don’t own a vehicle.
I can not drive but my household owns a vehicle.
I have no personal vehicle options.
There is public transportation near where I live that I can use.
I can use public transportation once I get in town.
I can get transportation to medical appointments.
I do not have public transportation I can use.
I am unable to get out of my house to use public transportation.


10. Do you purchase any independent living services with your own money?
If yes, please tell what they are.
If no, please say why not.

There are two more parts to this survey. When you click the next button, you will be taken to the OpinionPower site to finish the survey. To return to AbilityMaine, you can either paste the following link into your browser — http://www.abilitymaine.org — , or use the back button on your browser.