TEST FORM Muhsen Needs Assessment Survey InstagramThis field is for validation purposes and should be left unchanged.beginEmail* Phone*Individual InformationI am a* Parent/Guardian or Caregiver Individual with Special Needs Other… Explain here..Name* First Last Information of Individual with Special NeedsName* First Last Age* birth – 5 6-12 13-17 18-24 25-39 40+ Gender* Male Female Prefer not to say Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Diagnosis (select all that apply)* Attention-Deficit/Hyperactivity Disorder Autism Blindness Cerebral Palsy Deafness Developmental Delay Down Syndrome Epilepsy Hearing Impairment (hard of hearing) Learning Disability Muscular Dystrophy Physical Disability Speech Impairment Visual Impairment Other Other(Exlplain here)School Placement (Select all that apply)* Public School Private Therapy Center Homeschool Islamic School – Full Time Islamic School – Weekend Graduate Adult Program Does not apply Other Survey QuestionsName of your local Masjid*City*Country*Select CountryUnited StatesCanadaUKState*Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificProvinces and territories*Select StateAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonOn a scale of 1 to 10, how would you rate your family member's acceptance in the Muslim community?*12345678910Which supports would enhance participation from your Special Needs family member at the Masjid? (select all that apply)* Adult Life Skills Programs Access to Programs and Classes Accessibility Braille Quran Child Care Options Closed Captioning/Visual Resources Large Print Quran Open House for families with Special Needs Quiet Room Sensory Supports (Light & Sound) Sign Language Support Groups Weekend Schools Youth Options Other Would you and/or your Special Needs family member like to attend a gathering to meet other families?* Yes No Maybe Would you be interested in a caregiver/individual/sibling support group?* Yes No Maybe Would you be interested in volunteering to help with MUHSEN's mission?* Yes No Maybe Δ
