Assistive Devices 2011
Answers marked with a * are required.
1.
What type of device(s) did you receive from BDHHS?
Alarm Clock
Phone Signaler
Doorbell Alert
Videophone
Baby Monitors
Telephone
Personal Listening Device
Sound Maskers
TTY/Fax
Videophone Alert
Smoke alarm
Other
2.
Do you use this device everyday?
Yes
No
3.
Do you strongly agree that you are able to maintain your independence through the Assistive Device provided to you by BDHHS?
Yes
No
4.
Before you received the device(s) did you have difficulty doing everyday things?
5.
How has the device(s) changed your life?
6.
Has the Assistive Device improved the quality of your life?
Yes
No
7.
Was BDHHS staff knowledgeable on devices?
Yes
No
8.
Comments
9.
What's your gender?
Male
Female
10.
What's your age?
0-59
60-65
65+
11.
What's your ethnicity?
White/Caucasian
Black/African American
Hispanic/Latino
Asian/Pacific Islander
American Indian
Multi-Racial
Other
12.
What's your Zip Code?
19601
19602
19603
19604
19605
19606
19607
19608
19609
19610
19611
19612
19506
19508
19510
19512
19518
19520
19522
19526
19530
19533
19536
19540
19541
19543
19547
19550
19551
19555
19562
19565
19567
Out of County