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National Multiple Sclerosis Society

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DED Program Needs Assessment Survey

*1.

Question - Required - Which of the following best describes you?

Question - Not Required - What is your gender? Male
Female

Question - Not Required - What is your marital status?

Question - Not Required - What is your date of birth?

Month

Day

Year

Question - Not Required - Do you have children?

Question - Not Required - If you have children, please list their ages:

Question - Not Required - What is your primary ethnicity?

Question - Not Required - With whom do you live?
Please make between 1 and 3 selections from the choices below.

	A partner/spouse
	Children under 18
	Children over 18
	Other family members
	Alone
	A support person such as an aide
	Other residents in a nursing home
	Other

Question - Not Required - Where do you live?

10.

Question - Not Required - In what ZIPCODE do you live?

11.

Question - Not Required - When were you first diagnosed with MS?

Month

Day

Year

12.

Question - Not Required - The following represent concerns I have about the quality of MS care I currently receive: (choose all that apply)
Please make up to 9 selections from the choices below.

	My doctor is not up to date on the latest MS treatments
	My doctor does not listen carefully to me
	My doctor does not understand me and my health care needs
	My doctor does not explain things to me in a way I understand
	MS care is TOO expensive
	It takes too long to get an appointment
	My doctor does not have enough information about MS to make decisions about my care
	Lack of adequate insurance coverage
	I live in an area with a limited choice of doctors.

13.

Question - Not Required - How would you like to be informed about local NMSS chapter programs and events?
Please make between 1 and 3 selections from the choices below.

	Regular mail
	e-mail
	NMSS Chapter Newsletter
	Local NMSS chapter website
	Facebook

14.

Question - Not Required - If you have NOT recently participated in a program sponsored by your NMSS chapter, please mark the reasons why not:
Please make up to 9 selections from the choices below.

	I had no transportation
	The day of the week was not convenient for me
	The location of the event was not convenient for me
	The time that the event was held was not convenient for me
	I have not been interested in the issues or topics presented
	My MS symptoms prevent me from leaving my home
	I was not informed about these events
	I would need someone to accompany me and provide assistance
	Other

15.

Question - Not Required - What would encourage you to attend a group meeting or other live program sponsored by your NMSS chapter? (choose all that apply)
Please make up to 5 selections from the choices below.

	If the programs were held in the evening
	If the programs were held on weekends
	If the programs were closer to my home
	If I had transportation to the program
	Other

16.

Question - Not Required - What is the best day of the week for you to participate in a program?
Please make between 1 and 3 selections from the choices below.

	Monday
	Tuesday
	Wednesday
	Thursday
	Friday
	Saturday
	Sunday

17.

Question - Not Required - What is the best time for you to participate in a program?
Please make between 1 and 3 selections from the choices below.

	Morning (8am - 10am)
	Mid-Day (10am - noon)
	Afternoon (noon - 5pm)
	Evening (5pm - 9pm)

18.

Question - Not Required - Which THREE of the following do you think it is most important for the chapter to provide? (choose up to THREE)
Please make between 1 and 3 selections from the choices below.

	Fundraising opportunities/events
	Information on MS
	Referrals to MS specialists or health care professionals
	Physical health education programs
	Programs or information about emotional and mental health issues
	Information and programs about life and financial planning
	Social Activities
	Employment counseling
	Help to access and coordinate benefits and services
	Advice on legal issues
	Information about respite care
	Advocacy
	Provide access to financial assistance

19.

Question - Not Required - Which of these program topics would be of interest to you/would you consider attending? (choose up to 5)
Please make up to 5 selections from the choices below.

	Symptoms management
	Activities of daily living, such as bathing, toileting, and eating
	Financial management/difficulties
	Getting out of the house
	Finding/accessing transportation
	Dealing with sadness and other emotional issues
	Finding good health care
	Managing fatigue
	Managing memory, reasoning, and/or other cognitive functions
	Finding and/or maintaining employment
	Maintaining/participating in social activities
	Issues with insurance coverage, reimbursement for health care and/or medications, paying for health care and/or medications
	Coordinating the care, benefits, and services that I need
	Relationship/intimacy issues
	Family relations/family support issues

20.

Question - Not Required - Please provide us with your name and e-mail address (optional).

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