Survivor and Family Members Questionnaire

Governor John A. Kitzhaber, M.D., formed The Governor's Task Force on Traumatic Brain Injury with Executive Order NO. 01-02. One of the charges to the Task Force is to

We request that you take the time to complete the following questionnaire. The form allows you to comment in narrative form so that you are not limited to the choices offered. All of your responses will be confidential. You may fill in your name if you wish, but it is not necessary.

You can also help by helping us reach others who may be interested in commenting. To request that we mail or email a questionnaire to someone else, please provide us with their address or email address in the space provided. Thank you for your involvement.


 1. Are you a:
Person with a brain injury
Family member or friend


2. If you are a person with a disability, please check only ALL that best describes your disability:

Traumatic Brain Injury
Other Brain Injury
Spinal Cord Injury


3. I consider the major issues associated with my injury to be (check all that apply):



4. Do you have additional comments about condition that you would like to share with us:



5. Age at which brain injury occurred:


6. At this point in time, how satisfied are you with your life? Select the number below that best describes your current feelings of life satisfaction. "1" means "I am very dissatisfied with my life. " "5" means "I am very satisfied with my life."

 1 2 3 4 5


6a. Do you have additional comments about your life or condition relating to your life satisfaction that you would like to share with us:



If you don't mind, please tell us about yourself:

7. Age:


8. Race: (Check all that apply.)

American Indian or Alaska Native
Pacific Islander
Hispanic or Latino
White non Hispanic
Don't wish to answer


9. Type of area you live in:

Urban (city)
Rural (country)
Suburban (small community near a city)



10. Zipcode you live in:



11. What is the highest level of education you have completed?



12. Below are some questions that will let us know what you consider your most important issues/needs. Please rate each of these by their degree of importance:



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Medical issues/Medications

Memory/Cognitive issues

Attention/Focusing Skills

Anger Management Issues



Housing Issues

Transportation Issues

Public Awareness of TBI


13. Please feel free to make additional comments on other issues/needs not listed above.



14. Below are some questions that will let us know what you consider the most significant obstacles/barriers to receiving services. Please rate each of these by their degree of significance:



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Living in rural area

Insurance doesn't pay for needed services

Insurance coverage stops too soon

Poor communication with service providers

Not meeting eligibility requirements

Services not designed to meet individual needs

Hard to find helpful information about services

Hard to know where to start to get services

System is confusing





16 Types of assistance you are receiving: (Check all that apply.)

SSI - Social Security Insurance
SSDI - Social Security Disability Insurance
OHP - Oregon Health Plan
Food stamps
Vocational Rehabilitation
Transportation Assistance
Family Respite Services
Housing Assistance
Supportive services
In-home Care
No Assistance




18. Overall, how satisfied would you say you are with Oregon's response, programs, and policies for persons with brain injury?

Very satisfied
Somewhat Satisfied
Not satisfied
Not at all satisfied
Don't know


19. If you (or your loved one) are currently receiving services, how are they working? Select the number below that best describes your opinion. "1" means "services are terrible." "5" means "services are great."

 1 2 3 4 5


20. In your opinion, what change or changes in services would have the most positive impact on you or your family member?



21. Please use this space to add any additional comments, recommendations or to ask any questions that you have.




22. If you would like to be put on our email mailing list, please fill in your email address below.



23. If you know of others who would like to receive this survey, please fill in their names and addresses, or email addresses, and send or fax to addresses below.


 If you would like a copy of your survey, please print this survey before clicking submit button.


The Governor's Task Force on Traumatic Brain Injury is supported by grant number 1 H21MC00043-01 from the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
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