MUHSEN
Needs Assessment Survey
*PLEASE NOTE THAT YOUR RESPONSE WILL ONLY BE USED BY OUR ORGANIZATION. YOUR IDENTITY WILL BE KEPT CONFIDENTIAL.* *
Your answer
Name of Family Member with Disability, First and Last *
Your answer
Age of Family Member with disability *
Your answer
Email Address *
Your answer
Address of Person with Disability *
Your answer
If your family member has multiple disabilities/condition not listed above, please specify details below.
Your answer
On a scale of 1 to 10, how would you rate your family member's acceptance in the Muslim community?
1 is the least and 10 is the greatest
Not at all
Completely Accepted
Type of Disability *
Please check all that apply
Required
On a scale of 1 to 10, how would you rate your family member's accessibility to Masjid related events? (Jummah, Tarawih, Eid Prayer, Carnivals)
1 is the least and 10 is the greatest
Not at All
Completely Accessible
Which supports would enhance participation from your Special Needs family member at the Masjid?
Please check any that apply
How can the Muslim community best assist you and your family member with a disability?
Choose one or more of the following
Would you and/or your Special Needs family member like to attend a gathering to meet other families?
Would you be interested in attending a Masjid-based support group for parents / caregivers?
Would you be interested in a Masjid-based siblings support group for your child/children?
What can Muhsen do to support you or your family member?
Your answer
*Please Note that your response will be used only by our organization. Your identity will be kept confidential.
Your answer
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