Needs Assessment/Family Survey

Posted by on Dec 8, 2011 in | Comments Off

This needs assessment survey is for all Family Support Services (FSS) families in Franklin County to determine your funding needs, priorities and views about using Family Support Services. Your opinions on current Family Support issues and preferences on how the funding is currently administered are very important to the future of the department. The information you provide in this survey will help the Family Support & Respite office formulate recommendations and procedural revisions that will be presented to the Franklin County Residential Services Board. Please take the time to complete this short survey to let the Family Support & Respite office know of your needs and opinions.

NOTE: IF YOU COMPLETED THE SURVEY PAPER VERSION DO NOT COMPLETE THE ONLINE SURVEY. IF YOU HAVE ANY QUESTIONS CONTACT OUR OFFICE AT 614-844-5847.

1. Have you used Family Support funding since July of 2011?
 Yes No

2. Do you anticipate using Family Support funding between July 2012 and June 2013?
 Yes No

3. Since the state Family Support funds are limited, the Board would like to know the families
priorites of service, to allocate the Family Support funds proportionately to each category:
Please indicate your family's priorites for funding:

Respite:
 No Need Low Priority High Priority

Adaptive Equipment :
 No Need Low Priority High Priority

Special Diets:
 No Need Low Priority High Priority

Home Modifications:
 No Need Low Priority High Priority

Counseling Training/Education:
 No Need Low Priority High Priority

Other (if any):

4. What is the age of the individual(s) in your home with a developmental disability?

5. Check any Franklin County Board programs or services your family member(s) with a
developmental disability is receiving or has ever received?

Other Program (if any):

6. Total Number of years involved with the Franklin County Board of Mental Retardation and Developmental Disabilities:

7. Choose the degree to which you feel your family member(s) has benefited from Family Support:
 Not At All Some A Great Amount

8. How satisfied are you with the services/support received from Family Support & Respite Services?
 Not At All Some A Great Amount

9. Choose the degree to which you feel the Family Support & Respite staff shows respect for you, your ideas and input:
 Not At All Some A Great Amount

10. Would an increase in Family Support & Respite Services effect your involvement in activities outside the home?
 Not At All Some A Great Amount

11. Does the Family Support & Respite Services address the needs of your other children and extended family?
 Not At All Some A Great Amount

12. Are there any other services you would like to see offered through the Family Support Office that are not presently available?
 Yes No

If yes, please describe: (Max 250)

Comments? (Max 250)

OPTIONAL

Your Name

Your Address

Phone Number

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