INFORMATION SURVEY

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.

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

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."

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:

8. Race: (Check all that apply.)

9. Type of area you live in:

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:

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:

 15. Please feel free to make any comments on any other significant obstacles or barriers that you have or are encountering.

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

17. What assistance or services are you receiving that have not been listed, or additional comments on items listed above.

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

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."

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.