Please take a few moments to complete our survey related to utilizing the Consumer Involvement Fund (CIF). Your response(s) will help us address the needs of people with developmental disabilities and their family members. Your survey and responses will help us achieve our goal of providing financial assistance to Alabamians with developmental disabilities in helping enhance, promote, and support independence, advocacy, productivity, and inclusion. Rate your knowledge of one or more of the following items listed below before attending the requested conference. Thank you for your valuable input. Alternate formats are available upon request. (Please use the translation option at the bottom of this page to translate this information into other languages as needed.)

For the following: 1 = Not Very Much - 5 = A Lot

Knowledge of my disability or my family member’s disability
12345

Knowledge of disability related services, programs, supports, etc.
12345

Knowledge of, or use of, advocacy or self-advocacy skills
12345

Knowledge of how to share information with disability or medical professionals, teachers, parents, etc.
12345

Knowledge of, or participation in, public policy or advocacy events or activities related to disability
12345

Knowledge of, or participation in, leadership opportunities such as cross disability boards and coalitions
12345

Knowledge of information (new technology, equipment, services, etc.) that could assist me or my family member with accessing or participating more in the community
12345

Knowledge of current disability related information, skills, etc.
12345

Other
12345

Have you used the Consumer Involvement Fund before?
YesNo

Have you attended this conference/event/activity before?
YesNo

If supported by the ACDD to attend this conference, event, or activity, how many hours are you willing to spend sharing any information received with others?
Less than five hoursSix to 10 hoursMore than 10 hoursOther

Do you live inside the city limits?
YesNo

If not, then please list the county that you live in

RACE
CaucasianAfrican AmericanHispanicNative AmericanAsianOther

PLEASE CHECK THE APPROPRIATE BOX (REQUIRED):
I am a person with a developmental disabilityI am a parent of a child with a developmental disabilityI am the guardian of a person with a developmental disabilityMy family member is an adult with a developmental disability

GENDER (OPTIONAL)
MaleFemaleOther

GEOGRAPHIC LOCATION (OPTIONAL):
I am a Resident of an Urban Area (More than 50,000 people live there)I am a Resident of a Rural Area (Less than 50,000 people live there)

What conference or event are you seeking funds to attend?

Note: Please provide any information on the event that clearly explains what you want to attend, such as the agenda, brochure, and/or flyer.

Please indicate funds below.

HOW MUCH YOU CAN PAY (YOUR FUNDS)? HOW HOW MUCH FUNDED BY OTHERS (OTHER AGENCIES)? HOW MUCH REQUESTED FUNDS (FUNDING FROM ACDD CIF)?

REGISTRATION

PERSONAL ASSISTANCE

HOTEL/LODGING

MILEAGE

CHILD/RESPITE CARE

AIR OR BUS FARE

MEALS

OTHER

TOTALS

YOUR FUNDS

FUNDS FROM OTHER AGENCIES

FUNDS FROM ACDD CIF