Survey Questionnaire

Please use this survey questionnaire to notify us of changes in your program or to list other programs that should be included in the National Directory of Alcohol and Other Drugs:Prevention and Treatment Services for the Deaf.
Also please let us know if the changes are for a complete change, an address change, a few changes. If you need to change some, please just fill in specific fields.

Thank you for your time and effort in completing this survey.

Questionnaire:

Name of Program:
Address:
City:
State:
Zip:
County:
Phone: (Voice) (TTY) (FAX)
Contact Person:

 

Name of Host Institution:
Address if Different:

 

Year in which program was established:

 

Ownership: Private for Profit State/Local Government
  Federal Government Private Nonprofit
  Other (Lists:)

 

Number of Staff: Full-time Part-time  
  Number of Staff who are Deaf
  Number of American Sign Language Skilled
  Number of Multi-lingual (Spanish, etc.)  
Interpreters: Full-time Part-time Contractual

 

Which Services Offered: Alcoholism In-patient
  Drug Abuse Out-patient Treatment
  Information/Referral Family Programs
  Prevention/Education Aftercare
  Assessment/Intake Halfway Housing
  Detox All Services
  Other

 

Number of Interpreted AA Meetings: In-house In area

Number of Special Devices for the Deaf: Closed Captioning TTYs

Number of Deaf Clients Served: Past 6 Months Past Year

This program is accessible to the following ages: Under 18 50-65
  18-25 Over 65
  25-50 All Ages

 

This program is accessible to the following populations:
  Hispanic Developmentally Disabled
  Native American Mentally Ill Chemical Abusers
  Women Deaf
  HIV Positive People DWI
  People with AIDS All following populations
  Other Disabilities (Lists:)

 

Financial arrangements accessible to clients:
  Self-pay Medicare Medicaid
  Sliding Fee Scale   SSI/SSD
  Private Insurance (List:)

 

Publications: (Please attach or mail.)
  Type of Publication:
  Name of Publication:
  Contact Person:
  Phone: (if different from above) TTY

 

Please supply information on other drug related programs in your area or state that serve the deaf. Include name, address, contact person and phone number. Attach or mail additional sheets or copies of existing lists you may have.

 

Name:
Address:
City:
Phone:
Contact Person:
   
Name:
Address:
City:
Phone:
Contact Person:
   
Name:
Address:
City:
Phone:
Contact Person:

 

Date Survey Completed:

 

(When you complete the survey, submit it. Thank you!)

 

(If mailing publications, please send to the address below.)
 
  SAISD
Substance and Alcohol Intervention Services for the Deaf
Rochester Institute of Technology
August Center
115 Lomb Memorial Drive
Rochester, NY 14623-5608