2. Special Needs and Disabilities Committee Community Survey

4. 1. Residency (Choose only one)*

   1. Live
   2. Work
   3. Frequent as a visitor
6. 2. Do you or does someone in your home have a disability?*

   1. Yes
   2. No
7. 3. If you answered Yes to Question 2, what type of disability(s) diagnosis pertains to you or your household member? Please check all that apply:

   1. Autism Spectrum Disorder (ASD)
   2. Deafness
   3. Intellectual Disability
   4. Mental Health
   5. Specific Learning Disability (SLD)
   6. Traumatic Brain Injury
   7. Invisible Disability
   8. Orthopedic Impairment
   9. Visual Impairment, Including Blindness
   10. Other
   11. Do Not Wish to Provide
9. 4. Do you know where to access information to help yourself or a family member with a disability?*

   1. Yes
   2. No
   3. Other
10. If you answered Other to Question 4, please elaborate.
12. 5. If you answered Yes to Question 4, please provide a list of resources you or a household member have utilized.
14. 6. Do you believe there are adequate resources in Monroe for individuals with disabilities and/or their families?*

    1. Yes
    2. No
15. 7. Do you believe there are adequate extracurricular activities offered in Monroe to individuals with disabilities?*

    1. Yes
    2. No
17. 8. What do you feel is the highest priority for the City of Monroe to improve programs and activities for individuals with disabilities?*
19. 9. Do you believe that the City of Monroe does a satisfactory job communicating services to individuals with disabilities?*

    1. Yes
    2. No
21. 10. Have you ever experienced any physical barriers (parking, ramps, restrooms, accessibility) while visiting one of the City of Monroe's parks or facilities or participating in a program managed by the City of Monroe?*

    1. Yes
    2. No
    3. Not Applicable
23. 11. If you answered Yes to Question 10, please provide the location and/or program and the physical barrier.
25. 12. What do you believe is the highest priority for the City of Monroe to improve facility accessibility for individuals with disabilities?*
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field