The Central Coast Center for Independent Living (CCCIL) provides information on Assistive Technology as one of our core services. In order to provide the best services possible to our consumers we need to establish what your needs are. Please take a few minutes to answer the following questions:
1. Do you have a disability? Y N If so, what is the disability?
2. Would the use of assistive technology help you in your daily life? Y N
3. Do you use any type of assistive technology in your daily life? Y N If so, what?
4. Where would you get information about assistive technology aparatus and how would you get the aparatus?
5. Have you encountered any problems using your assistive technology? Y N If so, what?
6. Did you have any problems acquiring your assistive technology? Y N If so, what?
7. Did you experience any problems finding a source for your assistive technology? Y N If so, what?
8. Did you experience any problems funding your assistive technology? Y N
9. Did you use any organization to help acquire your assistive technology? Y N If so, which one?
10. Have you had any trouble getting repairs/services for your assistive technology? Y N If so, what?
11. Would you like CCCIL to contact you regarding AT? Y N
If so, please type your name and contact information:
Name: Address: City, State, Zip Code: Phone: Email: Fax:
You may use the input area below to add any other comments or concerns: Other comments
Lindy Peters Assistive Technology Coordinator
Santa Cruz County (831) 462-8720 ext 22 (v)(831) 462-8729 (TTY)
Monterey and San Benito Counties (831) 757-2968 ext 22(v) (831) 757-3949 (TTY). e-mail: lpeters@cccil.org