Mayor's Office for People with Disabilities

We Want to Hear from You

Please answer the following questions to the best of your ability.  Although we may share your comments and suggestions, all names and email addresses are confidential.

 1. Name (2) issues facing you right now, please?
 
1.

2.

 2. Are you prepared for a disaster or emergency?
  Yes ... No
 3. What programs or services would you like to see developed for people with disabilities?
 (please be specific and brief)
  a.

b.

 4. Are you interested in participating in a program development committee?
 

Yes ... No

Phone:

Email:

 5. Have you attended any forum or event sponsored by MOPD? If so, please name below.
 

Yes ... No

a:

b:

c:

 6. What would you improve about any of those events? What would you add? What would
 you eliminate? Please be specific.
 

a:

b:

c:

 7. What concerns would you like to see addressed at MOPD's next forum / workshop?
 Check all that apply.
 

Self Advocacy Training ... Who Do I Call When ... Housing

... Legal ... Transportation ... Other

ABOUT YOU

Name:
Email:
Phone:
Age Group: 0 - 17 ... 18 - 35 ... 36 - 51 ... 52 - 67 ... 67+

 

Race / Ethnicity:

African American ... Asian (Chinese, Korean, Japanese, Vietnamese, Etc.) ... Caucasian ... Hispanic ... Native American ... Pacific Islander ... Other

 

You Are A:

Person with a Disability

Parent of a Person with a Disability

Caregiver / Personal Aide to a Person with a Disability

Veteran with a Disability

Disability Advocate