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Home
- Like Us On Facebook
The Need
- Accessible Criteria
- Helpful Links
Solutions
- What Is Accessible Design?
- Assistive Technology
Resources
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

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Basic Information
Year of Birth*
County of Residence*
Zip Code*
Marital Status*
Education Completed*
Work Status*
Disability*
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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