Attachment 1 - Questionnaire (HREOC - 8-11-99)
Introducing 'ParaQuad C.H.O.I.C.E. On-line'
The ParaQuad Assoc. of Tasmania Inc has just received a Grant from the Commonwealth Dept of Communication & Arts to develop a Website and also to purchase some computers and special equipment for people who meet specific criteria. The eligibility criteria is: people who have a spinal injury acquired through disease, trauma, neurological disorder or genetically (including, for this project) cerebral palsy, MS, polio and other neuromuscular or neurological diseases. These people would be unable to use any means of public transport (even if it was available) and are dependent on their own vehicle, vehicle of family, friends or carers or taxis for their transportation. A small number of Tasmanian residents, who meet the criteria, will have the opportunity to have a computer in their home to use for whatever purpose they wish. (You do not have to be a member of ParaQuad to apply.)
All people applying will not automatically be given a computer. You will need to be assessed, against specific criteria, first. This questionnaire gives you, or a family member, the opportunity to tell us why a computer in your home would be beneficial to you. Send your filled in Questionnaire to:
ParaQuad 'C.HO.I.C.E. Online'
ParaQuad Assoc. of Tas Inc
PO Box 1528 NSDC
GLENORCHY 7010
Deadline for return of Questionnaire is Friday, 18th June, 1999.
In addition we will be having on-line access to:
· fully wheelchair accessible accommodation and leisure venues in Tasmania
· comprehensive listing of equipment available for loan / hire / sale in Tasmania
· A unique 'living free from injury' concept especially targeted at children and youth.
· 'chat facilities', surveys, questionnaires etc.
· Medical Equipment Supply Service (M.E.S.S.)
· education and awareness training sessions (from time to time) utilising the services of professionals with expertise in the following areas; new product usage; continence education; assistive technology education/training etc.
· internet and email access (20 hours monthly - no charge to you for one year at least)
What does the name C.HO.I.C.E. stand for?
C. Communication
H. Home Access
O. Options for Choice
I. Information
C. Computer hardware / software assistance
E. Electronic mail and Internet
We will be selecting participants with / without computers to participate initially. The numbers of actual participants funded will be determined by each individual's specific requirements when assessed.
We hope that we have encouraged you to fill in the Questionnaire because we are very keen to support people such as yourself. Maybe this will be the first time you have ever been asked whether you would like a computer - so maybe you haven't really thought much about having a computer in your home.
If you apply and are unsuccessful this time, we will be asking people next year to apply again so, please sign here if we can keep your application until next round.
Name:______Signature______
(Family member can sign on your behalf)
If you are unsure of any part of this Questionnaire or have any questions please phone Jenny Stanzel on 6272 8816 or 6273 8043 and she will discuss any queries you have.
1. What is your disability? (We don’t need too much detail but we need to know if you fit the criteria on page one.)
2. a) Do you have mobility difficulties? Yes [ ] No [ ]
(If you use mobility aids ie wheelchair, walking frame, walking sticks, leg braces/calipers, we would appreciate a sentence (or two) on how difficult it is for you to get around your home or town.)
b) If you use a wheelchair - do you use it:
a) all the time? Yes [ ] No [ ]
b) part time? Yes [ ] No [ ]
3. Do you have:
i) full movement of your arms? Yes [ ] No [ ]
ii) part movement of your arms? Yes [ ] No [ ]
4. Do you think you would need special equipment to allow you to use a computer with ease? Yes [ ] No [ ]
(There are many computer accessories to assist you to use the computer more easily ie.
special keyboards, 'voice speak' software for people with speech and vision disabilities, special 'mice', etc. This will be discussed further if you are assessed.)
5. a) Tell us about the place where you live. Is it in a major town, the suburbs, a rural
community or out of town.
b) Would you like to comment on how you feel having to depend on family / friends for your transport needs.
c) What difficulties do you have with physical access in your home or town shopping centre, library etc. (Maybe your home is not completely accessible, or maybe it is too difficult, or you are too tired, or cant be bothered to go to town because of bad access into shops etc.)
7. Do you have the use of a computer in your home? Yes [ ] No [ ]
If not, do you have the use of one elsewhere in the
community ie friends, library, family etc. Yes [ ] No [ ]
If yes:
a) Do you use it? Yes [ ] No [ ]
b) How often? ______
c) What do you use it for?______
Would you like to comment further: ______
______
______
8. Do you have:
a) use of internet / email? Yes [ ] No [ ]
b) special equipment to use the computer? Yes [ ] No [ ]
c) special equipment to make it easier? Yes [ ] No [ ]
d) all the equipment you need? Yes [ ] No [ ]
g) would you like more training so you can make the
most of your computer? Yes [ ] No [ ]
Would you like to comment further: ______
______
______
9. If you don’t have a computer in your home can you tell us what appeals to you most
about having one for your personal use? (Maybe this will be the first time you have
ever been asked - so maybe you haven't really thought much about it. It may be for leisure, education, games, communicating with other people, searching for information etc. This is your opportunity to think about what a computer could offer you.)
10. We would like you to tell us anything else about your life that you feel would assist
us in understanding how your lifestyle would become more enjoyable and fulfilling by having a computer and access to internet / email. (You or your family can write whatever you feel in this part. We want to stress that we will be giving you training on how to use the computer and internet if you are chosen for this project.)
If you feel there is not enough space for you to comment on any question please attach a separate page with your comments.
Please fill in your details here:
Surname:______First Name:______
Address: ______
______
______Postcode:______
Date of birth: (not essential) ____/____/____
Phone No.: Fax: Email: (If available)
______
If filling out this survey on behalf of the person above, please indicate your:
Name: ______
Address: (If different from above) ______
______Postcode: ______
Phone No: ______Fax: ______Email: ______
Relationship to the applicant: ______
Finally:
Thank you for taking the time to fill out this Questionnaire. All applicants who fit the criteria will be considered and advised if successful for the assessment. The assessment will be arranged at a time suitable to the applicant.
This assessment will determine what your specific needs are in relation to computer and equipment. When the equipment is set-up in your home we will organise training for you.