Step 1 of 6 16% Section 1: Reasons for Seeking ServicesWhat is your current relationship with CBVI? (Check all that apply.)(Required) Currently receiving services Received services in the past Family member is/was receiving services Other Other(Required)What were the main reason(s) you first sought services? (Check all that apply)(Required) Help finding a job Help keeping my current job Advance in my employment Other Other(Required)Please rate the extent you agree to the following statement: My reasons for seeking services were clearly understood by staff.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required) Section 2: Service Access & DeliveryInstructions: Please respond based on your experience in the last 12 months. Use the 4-point scale below where indicated and select "Does Not Apply" when an item does not apply.I was/am able to access my counselor without delays.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)I was/am able to access services without delays.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)The services I receive(d) were provided in a convenient location or format (e.g., in-person, virtual, community-based, etc.).(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)When I received services, I was offered training in blindness skills (e.g., Braille, orientation and mobility, adaptive technology).(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyBrailleOrientation and mobilityAdaptive technologyHome managementI am confident in my ability to use alternative techniques (e.g., Braille, assistive technology, nonvisual travel skills) to complete daily tasks and work activities.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyBrailleAssistive technologyNonvisual travel skillsHow can CBVI better help you in this area?(Required)CBVI staff assist(ed) me in exploring my interests, skills, and abilities.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)CBVI staff help(ed) me in developing an employment goal consistent with my interests.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)Overall, I am satisfied with how my employment plan was developed.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)My plan includes/included all of the necessary services to help me achieve my goals(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)CBVI staff assist(ed) me in getting the appropriate training (e.g., Skills for Independence, vocational or college training) to obtain a job or reach my vocational goal.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)Any barriers I experience(d) were addressed to my satisfaction while receiving services.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)Did you achieve or are you in the process of achieving your employment goal?(Required) Yes No Please explain.(Required)What additional skills or training would have better supported your independence or employment goals?(Required)What barriers, if any, did you face in receiving services? Please describe.(Required) Section 3: Communication & RespectInstructions: Please respond based on your experience in the last 12 months. Use the 4-point scale below where indicated and select "Does Not Apply" when an item does not apply.CBVI staff treated me with courtesy and respect.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)CBVI staff explained information clearly to me.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)CBVI staff encouraged me to ask questions and share my concerns.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)CBVI staff took my complaints and concerns seriously.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)What could staff do to improve communication with you?(Required)Section 4: Responsiveness & TimelinessInstructions: Please respond based on your experience in the last 12 months. Use the 4-point scale below where indicated and select "Does Not Apply" when an item does not apply.CBVI staff responded to my calls, emails, or questions in a timely manner.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)CBVI staff communicated with me effectively.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)CBVI staff communicated with me in a timely manner.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)CBVI staff were responsive to my needs.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required) Section 6: Choice & Service ProvidersInstructions: Please respond based on your experience in the last 12 months. Use the 4-point scale below where indicated and select "Does Not Apply" when an item does not apply.I understand (understood) that I have the right to choose the provider I want for my vocational rehabilitation services.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)My service provider(s) communicated with me effectively.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)My service provider(s) communicated with me in a timely manner.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)I was satisfied with the services I received from my provider(s).(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)Please provide any additional information you want to share about your services from service providers.(Required) Section 7: Overall SatisfactionOverall, I am satisfied with the services I received from CBVI.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)Overall, the VR services I received met my needs.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyHow can CBVI improve in this area?(Required)I am satisfied with my current employment choice.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyPlease explain.(Required)If a friend or family member needed similar services, I would recommend this program.(Required)Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not ApplyPlease explain.(Required)Are there additional services you feel would have been helpful?(Required)Do you have any other comments or suggestions to share?(Required) Demographic InformationThank you for sharing your experiences with CBVI. To finish, we’d like to ask a few questions about your background. These questions help us understand how needs may differ across groups and improve services for everyone. Your answers are confidential and reported only in group totals. You may skip any question you prefer not to answer.What is your age range?-- Select One --14-1718-2425-3435-4950-6465+Prefer not to sayWhat is your gender?-- Select One --MaleFemaleOtherPrefer not to sayOther genderWhat is your race/ethnicity? Check all that apply Black/African American Asian/Asian American White/European American Hispanic/Latino American Indian/Alaska Native/Alaska Native Native Hawaiian/Pacific Islander Other Prefer not to say Other race/ethnicityWhat language(s) do you primarily speak at home? English Spanish Mandarin Cantonese Portuguese Gujarati Hindi Tagalog (Filipino) Korean Arabic Italian Polish Haitian (Haitian Creole) Russian Other Prefer not to say Other language(s)What is your disability? (check all that apply) Blind Visually Impaired Deaf-Blind (Vision and Hearing Disabilities) Cognitive or Intellectual/Developmental Mental Health Physical/Mobility Health/Medical Other Prefer not to say Other disabilityWhere did you live in New Jersey at the time you received services?-- Select One --Northern RegionCentral RegionSouthern RegionPrefer not to sayHow would you describe the area you lived at the time you received services?-- Select One --UrbanSuburbanRuralPrefer not to sayWhat best describes your current work status?-- Select One --Employed full-time (35 or more hours per week)Employed part-time (less than 35 hours per week)Self-employedEmployed with a job coach or other supportNot employed - studentNot employed - looking for workNot employed or looking for workPrefer not to sayHow many hours per week do you work?Which of the following best describes your current Social Security benefit status?-- Select One --I am currently receiving Social Security disability benefits (SSI or SSDI).I used to receive Social Security disability benefits, but I no longer do.I have never received Social Security disability benefits.I’m not sure.Prefer not to say Δ
