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Home
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The Need
Accessible Criteria
Helpful Links
Solutions
What Is Accessible Design?
Assistive Technology
Resources
About Accessible Alabama
Access For All University
Research Briefs
Accessible Browser Settings
Photo Gallery
Resource Links
Housing Help
Housing Help
Birmingham
Dothan
Huntsville
Mobile
Montgomery
News
& Events
Contact
Us
Assessment
Home
/
Community Readiness Assessment
/
Assessment
Step
1
of
7
- Basic Information
0%
Basic Information
Year of Birth
*
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
County of Residence
*
Autauga
Baldwin
Barbour
Bibb
Blount
Bullock
Butler
Calhoun
Chambers
Cherokee
Chilton
Choctaw
Clarke
Clay
Cleburne
Coffee
Colbert
Conecuh
Coosa
Covington
Crenshaw
Cullman
Dale
Dallas
De Kalb
Elmore
Escambia
Etowah
Fayette
Franklin
Geneva
Greene
Hale
Henry
Houston
Jackson
Jefferson
Lamar
Lauderdale
Lawrence
Lee
Limestone
Lowndes
Macon
Madison
Marengo
Marion
Marshall
Mobile
Monroe
Montgomery
Morgan
Perry
Pickens
Pike
Randolph
Russell
St. Clair
Shelby
Sumter
Talladega
Tallapoosa
Tuscaloosa
Walker
Washington
Wilcox
Winston
Zip Code
*
Marital Status
*
Single
Married
Widowed
Divorced
Education Completed
*
High School Diploma or GED
Bachelors' Degree
Masters' Degree
Doctorate
None of the above
Work Status
*
Employed
Unemployed
Unable to work
Looking for work
Disability
*
Not applicable
Emotional/Behavioral Disorder
Mental
Physical
Communication
Describe your level of independence:
*
What are your impressions of the accessibility of your current living situation?
*
Good
Fair
Poor
Please describe your impressions:
*
Let us get to know you
Please complete the following questions so that we are able to learn a few basic things about you and your current living situation.
What type of community do you currently live in?
*
Metropolitan
Mid-city
Rural
Please specifically describe your current living situation:
*
Single family home
Extended care facility
Residing with parent or guardian
Other
Are you currently living where you are because there isn’t affordable or accessible housing?
*
Yes
No
Do you have children?
*
Yes
No
Which of the following best describes your current living situation?
*
With family, caregiver or legal guardian
In a group home or other care facility
Independent in the community either with or without supports
In this living arrangement,
*
I am responsible for planning and budgeting for expenses
Someone else manages the budget and expenses
Which of the following best describes the level of assistance you need with activities of daily living, such as bathing, dressing and gaining access to nutrition?
*
Consider the activity with which you typically require the most assistance.
Maximum assist -- I can complete 15 % or less of the steps required in order to complete these activities with or without the use of assistive technology.
Moderate to minimal assist -- I can complete 85% of the steps required in order to complete these activities with or without the use of assistive technology.
Modified/independent -- I can complete 100% these activities independently either with or without the use of assistive technology.
When you require assistance with activities of daily living as indicated above from whom do you primarily receive that assistance?
*
Family member(s)
Paid caregiver(s) whether from a public program or private resources
Friend(s) or other volunteer
What type of accessibility problems are you having with your current living situation?
*
Which of the following best describes your current employment status?
*
I am employed full-time
I am employed less than full-time
I am not employed
I have returned to school or other training program
How would you define your primary income source?
*
Wages from employment
Supplemental Security Income or Social Security Disability benefits
Settlement or other trust
Student financial aid
Which of the following best describes your primary health insurance coverage?
*
Employer-provided
On someone else's policy as spouse or dependent
Individual insurance plan through state/federal exchange
Public health insurance program such as Medicare or Medicaid
Student health insurance
Uninsured
Activities of Daily Living In And Outside The Home
Would you be able to complete the following daily living activities independently if your home were made accessible? Rate your need for assistance. Check the box below activities in which you are utilizing assistive technology.
Bathroom
*
No Assistance
Some Assistance
Complete Assistance
Using the restroom
Bathing
Shaving
Brushing teeth
Grooming
Assistive technology: bathroom
I use assistive technology in this area
Kitchen
*
No Assistance
Some Assistance
Complete Assistance
Cooking
Loading dishwasher
Washing dishes
Meal preparation
Reaching cabinets
Feeding oneself
Assistive technology: kitchen
I use assistive technology in this area
Laundry
*
No Assistance
Some Assistance
Complete Assistance
Load/unload machines
Fold/put up laundry
Assistive technology: laundry
I use assistive technology in this area
Bedroom
*
No Assistance
Some Assistance
Complete Assistance
Making bed
Dressing
Access to closet
Assistive technology: bedroom
I use assistive technology in this area
Environmental Control
*
No Assistance
Some Assistance
Complete Assistance
Cleaning
Open/shut doors
Electric outlets
Light switches
Thermostat
Mobility from room to room
Security and safety
Assistive technology: home maintenance
I use assistive technology in this area
Yard
*
No Assistance
Some Assistance
Complete Assistance
Mow lawn
Flowers/grass
Clean deck
Ramps
Assistive technology: yard
I use assistive technology in this area
Shopping
*
No Assistance
Some Assistance
Complete Assistance
Getting groceries
Running errands
Refilling prescriptions
Assistive technology: shopping
I use assistive technology in this area
Transportation
*
No Assistance
Some Assistance
Complete Assistance
Able to walk
Able to drive
Accessing the mailbox
Retrieving the newspaper
Assistive technology: transportation
I use assistive technology in this area
Finances
*
No Assistance
Some Assistance
Complete Assistance
Writing checks
Paying bills
Budgeting
Assistive technology: finances
I use assistive technology in this area
Mental Health and Well-Being
Rate yourself as truthfully as possible, in the following areas.
How would you rate your overall diet?
*
Very poor
Poor
Fair
Good
Excellent
Do you need guidance from a nutritional assistant?
*
No
A little
Some
A lot
Very much
How often do you smoke?
*
Never
A few times a year
A few times a month
A few times a week
Daily
How often do you drink?
*
Never
A few times a year
A few times a month
A few times a week
Daily
How often do you exercise or walk?
*
Never
A few times a year
A few times a month
A few times a week
Daily
How much time do you spend sitting each day?
*
Almost none
A little
A few hours
Most of the day
Almost all
Do you have access to medical coverage and care?
*
No access
Poor access
Fair access
Good access
Excellent access
How often do you feel tired or restless?
*
Rarely or never
Occasionally
Somewhat often
Very often
Always
Do you have access to assistance and the ability to complete basic daily living necessities?
*
Rarely or never
Occasionally
Sometimes
Almost always
Always
Do you have access to and funds for food, clothing and other basic necessities?
*
Rarely or never
Occasionally
Sometimes
Almost always
Always
How safe and secure is your living environment?
*
Very unsafe
Somewhat unsafe
About average
Fairly safe
Very safe
How financially secure are you?
*
Very insecure
Somewhat insecure
About average
Fairly secure
Very secure
What are some barriers that prevent you from being more physically active?
Check all that apply.
Too tired
Not enough time
Lack of facilities
Shift work, especially nights or overtime
Out on the road most of the time
Not encouraged to
Not motivated
Health issues
I am already active enough
Performance of Adult Roles
Rate yourself as truthfully as possible, in the following areas.
Which of the following do you use?
*
Check all that apply.
None
Cane
Wheelchair
Walker
3 Wheel Scooter
Do you anticipate needing to use a cane or wheelchair in the near future?
*
Yes
No
Are you able to drive a car?
*
Yes
No
Do you own a vehicle?
*
Yes
No
Do you have access to transportation services and are they accessible?
*
Yes
No
Do you know how to schedule a ride or use the public transportation system?
*
Yes
No
Do the barriers in your community inhibit you from going out?
*
Yes
No
Do you pursue any hobbies or activities during your free time?
*
Yes
No
Do you spend time with friends during your free time?
*
Yes
No
Are you able to work or volunteer?
*
Yes
No
Do you want to work or volunteer?
*
Yes
No
Please describe your favorite activities:
*
Have you developed personal relationships?
*
Yes
No
Do you have social support networks?
*
Yes
No
Are you able to exercise your basic rights as a citizen, such as voting, and are you informed in your community?
*
Yes
No
Personal Fulfillment
How satisfied are you with your current living situation?
*
Very unsatisfied
Somewhat unsatisfied
Neutral
Satisified
Very satisfied
How fulfilled are you in the following areas of life?
*
Very unfulfilled
Somewhat unfulfilled
Neutral
Fulfilled
Very fulfilled
Physical/Mental Health
Family
Friends
Work
Leisure
Marriage/Intimacy
Financial Security
Living Situation
Community Preparation
Do you feel you are a valued member in the following?
*
Check all that apply.
At work
With family
In the community
Within friendships
In your social networks
None of the above
How often do you feel optimistic about the future?
*
Often
Most of the time
Sometimes
Rarely
Never
I feel that I am able to make my own spiritual decisions:
*
True
False
Do you feel that you have responsibility and that your contributions are valued by others?
*
No
Not much
Somewhat
Mostly
Yes
Active Preparation and Planning
Please acknowledge the following:
I am open to learning new skills and behaviors, e.g., decision-making and group development skills.
I understand that listening and strong communications are of utmost importance when living in a community.
I am willing to share my values and life experiences with colleagues and community members.
I understand that other members of the community will have different values and beliefs than my own.
I have a clear picture of the challenges that can be faced while living independently.
My organization and family understand my commitment to this effort to live independently.
I am willing to look beyond my own needs to do what is best for my group and my community.
I am willing to accept and ask for help when necessary.
I understand the concept of sustainability and its implications for my choices.
If I did not have cash resources for food, I would access Supplemental Nutrition Assistance.
If I do not have funds for basic living necessities I know I am able to access resources in my community such as utility assistance (Community Action Partnership), rental subsidy (local Public Housing agency), medical care (Medicaid office), food stamps (DHR), etc.
If I am in need of cash assistance, I am aware that I should go to the local Social Security Administration office in my county.
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