Questionnaire

Please answer the following questions as accurately and honestly as possible.  Remember, no personally identifiable information is required.

1
Please indicate whether your are a  
Disabled Individual
2
Please indicate the nature of your disability.  If you suffer with more than one health condition, please show them all.  
3
Visual Impairment  
Hearing Impaired  
4
Physical Disability
Mental Health  
5
*Terminal Illness  
*Chronic Illness
6
*Other  
*Please Specify  
 
*
7
How long have you been disabled? ( in years)
0-1              1-3              3-5              5-7             7-10                +10
8
Do you receive 24 hour care or require that someone be with you at all times?Yes  No
 
9
Do you receive CPP Disability? Yes No
10
Do you receive Benefits from the Ontario Disability Support Program? (ODSP) Yes* No  
*If you answered Yes...Please skip to question 13  
11
Have you ever applied for ODSP? Yes No  
12
Have you been denied benefits from ODSP? Yes No  
13
Is there any other income coming into your home?  (Not GST, NCTB etc.) Yes No  
 
14
Please indicate your total family income per month.                                          
15
What is your monthly rent/mortgage?                                                              
16
Approximately, what do you pay for hydro/heat each month?                        
17
How many people (including you) live in your home?                          1  2 34 +4
 
18
If you need full time care or attendance, who provides that care?  
Spouse  
Other Family Member
Family Friend
Professional 
  No One  
19
Do you have enough money each month to properly feed yourself and your family?  
Yes  No
20
Approximately how much do you spend each month on groceries?                
21
Have you had to use a food bank or other support for groceries?                  Yes  No
22
Approximately, how often?
1-2 times year 
3-4 times Year
5-7 times year
Every month  
 
23
Do you have a drug card from ODSP, CCAC or the Trillium Drug Plan?Yes No  
24
Do you have a drug plan from private insurance or extended medical insurance? Yes No  
25
Are there any medications prescribed that you have to pay for? Yes No  
26
If Yes, how much do you pay monthly for those prescriptions?            
27
Do you require medical supplies or over the counter products/medications that you have to pay for? For example:  diabetic supplies, masks, tubing, gravol, hand sanitizer etc.
Yes No  
28
Approximately, how much does that cost? (Whichever is easier, monthly or yearly)
MonthYear
29
Are any assistive devices or medical equipment required for you? Yes No  
30
If yes, do you presently have everything you need? Yes No
31
Of the items you have, did you have to pay for all or any of it? Yes No  
32
Are you renting any of it? Yes No
33
Are you required to be on a special diet? (such as a diabetic diet) Yes No  
The following questions are regarding the Ontario Disability Support Program  
34
Do you understand correspondence or forms you receive from the ODSP? Yes No  
35
How easy is it for you to make contact with ODSP?
I am able to get through easily most times
I usually have to leave a message  
I have frequently had to leave more than one message
I have usually given up trying  
I get a professional (ie. Social Worker, MPP to call)
 
Please answer YES or NO to the following questions. 
36
In your experience, do you feel that in general, ODSP representatives…  
Treat you in a fair manner?            
Yes No   
Treat you with respect?                                
Yes No  
Are understanding?                         
Yes No    
Are informative?                            
Yes No   
Are helpful?                                  
Yes No
Treat you with suspicion?                 
Yes No  
Are courteous?                              
Yes No
Are intimidating?                            
Yes No  
Are abrupt?                                  
Yes No
Are capable?                                 
Yes No    
Are insensitive?                           
Yes No
Are knowledgeable?                       
Yes No  
Are clear about expectations           
Yes No
Are patient?                                  
Yes No  
37
Do you feel ODSP representatives are aware of the limitations your disability places on you?    
Yes No  
38
Please indicate any of the benefits or services you ARE RECEIVING.  Choose all that apply to you.
Nursing
Social Work
Speech Therapy
Personal Care
Physio Therapy
Occupational Therapy
Dietician
Dental Care
In Home Lab
Meals on Wheels
Other Benefit or Service
39
What 3 things are the greatest concern you have about your situation? (ie. Affordable housing, access to medications, income, services or support)  
 
1
 
2
 
3
40
Please indicate the one thing that could make a significant difference for you right now.  
41
What outside help or services could you benefit from that you are not receiving? (ie. Respite, hospice, housekeeping, transportation etc.)  
42
In a few words, how would you describe your overall living conditions, emotional state, relationship with your spouse/family and the support and/or services you are receiving.  
43
Is transportation an issue for you? Yes No  
44
From your personal experience, do you feel that others are able to understand your situation?  
 Yes     No  
45
Do you have any additional comments you would like to share?

Thank You for Taking the Time to Participate!