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NJDH Survey
Survey Responses
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Are you interested in living in affordable housing in New Jersey designed for those who are Deaf, Hard of Hearing, DeafBlind or Late-Deafened?
Yes
No
Clear selection
Where do you live now?
New Jersey
New York
Pennsylvania
Connecticut
Other:
Clear selection
What is your current living arrangement?
Rent
Own my own home
Live with family/friends at no charge
Live with family/friends and pay rent
Other:
Clear selection
If an apartment became available, could you move in three (3) months?
Yes
No
Clear selection
Please tell us the number of people in your household who are:
0
1
2
3
More than 3
Over age 55
45 - 55
21 - 44
Under 21
0
1
2
3
More than 3
Over age 55
45 - 55
21 - 44
Under 21
Clear selection
Check all that apply for the people in your household:
Deaf
Hard of Hearing
DeafBlind
Late-Deafened
CODA
Hearing
Mobility issues
Other:
Do you have a service animal?
Yes
No
Clear selection
How many bedrooms do you want?
1
2
3
Clear selection
Do you need a parking space?
Yes
No
Clear selection
Contact Information
Name:
Your answer
Street Address:
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
Phone:
Your answer
My phone is:
VP
TTY
Voice
Fax
Text
Other:
Clear selection
Email:
Your answer
Submit
Clear form
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