INDEPENDENT LIVING CENTER 

OF SOUTHERN CALIFORNIA, INC.

SANTA CLARITA NEEDS 

ASSESSMENT/SURVEY

 DEMOGRAPHIC

 NAME_________________________________________________________

 ADDRESS_____________________________________________________

 CITY:____________________________      ZIP:__________________________

 PHONE: __________________________FAX: _________________________

 EMAIL: ____________________________________________AGE: _______

 DISABILITY__________________________________ONSET: ____________

 ETHNICITY: ______________________________

 ANNUAL INCOME: _______________SOURCE OF INCOME: _____________

 NUMBER IN HOUSEHOLD:ADULTS__________CHILDREN__________

 INSURANCE TYPE: oPRIVATE INSURANCE  oMEDI-CAL    oMEDICARE

 ARE YOU PART OF A MANAGED CARE SYSTEM SUCH AS AN HMO? oYes oNo

TRANSPORTATION

 What principle mode of transportation do you use? oPersonal car oAccess Service, Inc.  oDial-A-Ride oBus   oOther mode of transportation___________

 What other modes of transportation do you use? oPersonal car oAccess Service, Inc.  oDial-A-Ride oBus   oOther mode of transportation______________________

 What, if any, problems do you experience using transportation systems?

oScheduling trips oEligibility oAccessibility oAbility to reach your destination

oOther_______________________________________________________

 What improvements to your current transportation options would best meet your needs?

oFlexible transit schedule oExpanded transit service oOther improvements

 _______________________________________________________________

 Is there a transportation issue that concerns you we did not ask?____________________________________________________________

 ________________________________________________________________

HOUSING

What is your current living situation?

oLive alone  owith Family  owith Roommate/Friends owith Personal Assistant oOther___________________________________________

Does your current housing meet your needs? oYes  oNo

Are you looking for housing? oYes oNo 

What obstacles prevent you from meeting your housing needs? oCost oLocation oAccessibility oLack of subsidized housing oInformation oOther__________________________________________________________

Is there any other housing issue that concerns you we did not ask?____________________________________________________________

MEDICAL

Are your medical needs being met? oYes  oNo    If no, what would you require to meet or satisfy your needs? ________________________________________________________________

________________________________________________________________

Where is your medical physician located?oSanta Clarita Valley oSan Fernando Valley oOther location_____________________________________________

What barriers have you experienced in accessing medical services? oFinding doctors that accept your insurance  oAccessibility  oProviding American Sign Language interpreter  oOther_______________________________________

________________________________________________________________

Is there a medical issue that concerns you we did not ask?____________________________________________________________

PERSONAL ASSISTANCE (P.A.)

Do you require assistance with activities of daily living? oYes  oNo   If yes:

What is your relationship with the P.A.? oFamily member  ofriend  oemployee oneighbor  oOther________________________

Do you receive In-Home Supportive Services (IHSS)? oYes  oNo 

If yes, do the number of hours meet your needs? oYes  oNo

If no, how many additional hours per month would meet your needs?_________

If you require a P.A. 24 hours a day, 7 days a week paid or unpaid, does that person receive time off? oYes   oNo

If yes, how much time?___________

If no, how much time do they need?_____________

Is there a Personal Assistant issue that concerns you we did not ask?____________________________________________________________

COMMUNITY RESOURCES

What community services/resources do you presently utilize? oSenior Center

oPublic Library oDept. of Rehabilitation oRegional Center oSocial Security Administration oParks & Recreation oBraille Institute oDept of Social Services oEmployment Development Dept. oMultiple Sclerosis Soc.  oCouncil on Deafness oCerebral Palsy Foundation oOther ________________________________________________________________

________________________________________________________________

________________________________________________________________

What resources/services do you presently need that are not available in Santa Clarita? ________________________________________________________________

________________________________________________________________

What barriers have you experienced in accessing Santa Clarita resources/services?

________________________________________________________________

________________________________________________________________

________________________________________________________________

______________________________________________________________

Would you benefit from a single source for information on community services/resources to meet your needs? oYes oNo

Is there a community resources issue that concerns you we did not ask?____________________________________________________________

EMPLOYMENT

Are you working? oYes  oNo   If yes, are you self-employed? oYes  oNo

If you are working, are you working ofull time or opart time?

If employed, are you working to your full potential? (skills, talents and abilities) oYes oNo 

If no, what are the barriers to working at your full potential?oTransportation  oaccessibility oskills development omore education ofear of losing medical insurance ofear of losing benefits oOther_____________________________

____________________________________________________________

Are you looking for work?oYes  oNo

What if anything has been a barrier to finding employment? oTransportation oaccessibility oskills development omore education ofear of losing medical insurance ofear of losing benefits oOther_____________________________

________________________________________________________________

Is there an employment issue that concerns you we did not ask?____________________________________________________________

SOCIAL

What, if anything, has been a barrier to participating in social activities? oTransportation  oenvironmental  oattitudinal  ofinancial  oopportunity 

oOther_______________________________________________________

Is there a social activities related issue that concerns you we did not ask?____________________________________________________________

GENERAL ACCESSIBILITY

Please rank accessibility of the following Santa Clarita public services or accommodations:

                                             Good                    Fair                      Poor

 Bus stops                               o                        o                         o

 Curb cuts                                o                        o                         o

 City sponsored events          o                        o                         o

 Library                                     o                        o                         o

 Parks & Rec.                          o                        o                         o

 Schools                                  o                        o                         o

 Restaurants                            o                        o                         o

 Theaters                                 o                        o                         o

 Supermarkets                        o                        o                         o

 Other_____________         o                        o                         o

 Is there an accessibility issue that concerns you we did not ask?____________________________________________________________

 Is there any category that we should have covered to better assess Santa Clarita’s services and needs for people with disabilities of which we did not ask?____________________________________________________________

 ________________________________________________________________

 ________________________________________________________________

 If you know anyone else who should complete this survey, please call us and we will provide a blank survey and self-addressed stamped envelope.  Please call 661-290-2569.