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<TITLE>Consumer Satisfaction Survey Access North - The Disability Community of The North</title>
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<table width="100%" border="0" cellspacing="0" cellpadding="0">
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</CENTER>
        <p align="center">&nbsp;</p>
        <p align="center"><font color="#CC0033" face="Arial" size="+2"><b>Consumer
        Evaluation of Independent Living Services Received</b></font></p>
        <p align="center"><font face="Arial" size="-1"><b>Your comments about the
        services you have received through CILNM are very important to us. The
        information you provide will help us provide more efficient, effective services in the future.&nbsp;
        Please take a moment to complete the survey below.&nbsp; We are grateful
        for you taking your time to provide feedback to us.</b></font></p>
        
        <!--automatically post date survey was completed to database-->
        
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          </form>
          <p align="left"><b><font face="Arial" size="-1" color="#003366">Survey Access Code<br>
          <input type="text" name="code" size="10"></font></b></p>
          
          <p align="left"><b><font face="Arial" size="-1" color="#003366">Phone Number<br>
          <input type="text" name="phone" size="10"></font></b></p>
          
          <p align="left"><b><font face="Arial" size="-1" color="#003366">First Name<br>
          <input type="text" name="fname" size="30"></font></b></p>
          
          <p align="left"><b><font face="Arial" size="-1" color="#003366">Last Name<br>
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          <p align="left"><b><font face="Arial" size="-1" color="#003366">Programs
          you participated in or services you received<br>
 		<input type="text" name="programs" size="60"></font></b></p>
 		
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              <tr>
                <td width="33%" valign="middle">
                  <p align="right"><b><font size="-1" face="Arial" color="#003366">I
                  received services</font></b></td>
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          <td width="33%">
              <p><select size="1" name="online">
                <option selected>In Person</option>
                <option>Online (by computer)</option>
                <option>Telephone Assistance</option>
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                </tr>
              </table>
            </div>
            <p>&nbsp;</p>
          <table border="1" cellpadding="3" width="100%" bordercolor="#336699" height="447">
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>
              1.&nbsp;As a result of direct services from CILNM (including 
              referral to another service provider) I have accessed previously unavailable transportation 
              (this could be because I didn't have the information before I 
              worked with CILNM)</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question1">
            <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="21"><font face="Arial" size="-1" color="#003366"><b>
              2.&nbsp; As a result of direct services from CILNM (including 
              referral to another service provider) I have accessed appropriate 
              accommodations to receive health care services 
              (this could be because I didn't have the information before I 
              worked with CILNM)</b></font></td>
              <td width="33%" height="21">
          <p align="center"><select size="1" name="Question2">
            <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>
              3.&nbsp; As a result of direct services from CILNM (including 
              referral to another service provider) I have accessed previously unavailable assistive 
              technology resulting in increased independence in at least one 
              significant life area (this could be because I didn't have the information 
              before I worked with the CILNM)</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question3">
            <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>
              4.&nbsp; I have become more involved in transportation, 
              healthcare, housing or assistive technology initiatives and issues within my 
              community that would increase community services available to people with 
              disabilities</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question4">
            <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>
              5.&nbsp; CILNM staff treated me with respect</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question5">
           <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>6.&nbsp;
                CILNM staff encouraged me to explore my options and try something new</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question6">
         <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>7.&nbsp;
                CILNM staff helped me to set my goals</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question7">
            <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>8.&nbsp;
                CILNM staff helped me to reach my goals</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question8">
            <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>9.&nbsp;
                CILNM provided information / services efficiently</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question9">
            <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>10.&nbsp;
                CILNM staff let me make my own decisions</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question10">
         <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>11.
                CILNM staff helped me to problem solve</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question11">
           <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>
              12.&nbsp; CILNM staff assisted in advocating for my rights</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question12">
            <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>13.
                CILNM assisted me in contacting others who would be helpful</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question13">
           <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
            </tr>
            <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>14.
                CILNM provided adequate follow up to their service to me</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question14">
          <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
   <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>15. CILNM 
              helped me to live more independently</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question15">
          <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
   <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>16. CILNM 
              provided me with a valuable service</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question16">
          <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
   <tr>
              <td width="67%" valign="top" height="22"><font face="Arial" size="-1" color="#003366"><b>17. 
              I would recommend CILNM to other people with disabilities</b></font></td>
              <td width="33%" height="22">
          <p align="center"><select size="1" name="question17">
          <option>Not Applicable</option>
            <option selected>Strongly Agree</option>
            <option>Agree</option>
            <option>Somewhat Agree</option>
            <option>Disagree</option>
            <option>Strongly Disagree</option>
          </select></p>
</td>
      



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            <tr>
              <td width="33%" valign="top"><font size="-1" face="Arial" color="#003366"><b>How
                has your situation improved?</b></font></td>
              <td width="67%">
                  <p><textarea rows="2" name="situation_improved" cols="50"></textarea></p>
              </td>
            </tr>
            <tr>
              <td width="33%" valign="top"><b><font size="-1" face="Arial" color="#003366">How
          might we improve our services?</font></b></td>
              <td width="67%">
                  <p><textarea rows="2" name="improve_services" cols="50"></textarea></p>
              </td>
            </tr>
            <tr>
              <td width="33%" valign="top"><b><font size="-1" face="Arial" color="#003366">Other
          Comments:</font></b></td>
              <td width="67%">
                  <p><textarea rows="2" name="comments" cols="50"></textarea></p>
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