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About Siletz news / (Siletz, OR) 199?-current | View Entire Issue (Jan. 1, 2010)
¡Please circle or complete the appropriate box. rou________ Are you a tribal member with a disability? Is any member of your family or any non-family member living under your roof a person ¡with a disability? Ilf all are not a person with a disability, please stop here. You do not ¡need to return the survey. I hank you lor your time. in anyone in the household is a person with a disability, please complete the questions in the appropriate column. _____ What is the name of the person with a disability ? What is the sex of the person with a disability? Please list the date of birth of the person with a disabilitv Ils the person with a disability a member of the Siletz Tribe? ¡What is the roll number of the person with a disabilitv? Ils the person with a disability a member of another Tribe?_______ 1 Please list the Tribe. | Roll number in the other Tribe? " plow would you describe the disability or disabilities'? Is the person with a disability in the Service? ¡Was the person with a disability in the Service'? pt the person was or is in the service, please complete the next five questions. otherwise skip to next section. IWhat were the veteran's dates of service? p\ hat wai7action/conflict(s) did the veteran serve in? Iw hat was the veteran's rank at discharge? Has the veteran applied with the V A for services? —— hat is the status of the veteran's application for benefits? Approved, [Denied, Pending, Don't Know _____________ Yes Family Member No Yes Non-Fam ily Member No No Yes I you cannot me et the Feb. 1 d eadline, please return at your e arliest possible J cc mvenience. Please send to: Sharmon Cook-Wright at P.O. Box 549, Siletz , OR 97380- 0549 or rctum to an area office. You_______ | Family Member | Non-Family Member | Male | Female "1 Male. | Female | Male | Yes | No ? Yes | No | Yes Yes | No | Yes I No | Yes P Yes Yes No No Yes No Yes No Is the person with a disability employed?_____ Is the person with a disability underemployed?______ Yes Yes No No Is the person with a disability interested in training and employment? Yes No I Yes Yes | Yes No No | “] No Female | ~| No 1 | No "1 Yes Yes No ~1 No "I Yes No ~1 Yes No Yes Yes No No Yes No ¡Begin again here: Has the person with a disability applied for vocational rehabilitation with the state, county or Tribe? pf yes, what was the outcome? ____________ Yes No Yes Yes_____ No No Yes No Please add comments; if necessary attach another sheet of paper. What do you see as barriers to the person with a disability's gaining satisfactory employment? Check all that apply._____ _________ _______ Lack of transportation ______ 1_______ Physical access problems __________ _______ Need for childcare ___________________ I_______ Need for housing ______ _______ No jobs in area ______ 1_______ Medical_______ : Other (write in) r T — — — _______________ ----------------- ----- Is there anything we could help you with? Check all that apply. 1______ Employment_______ ____ _____ 1______ Housing _________________ 1_____ Home Improvement_____________ I_____ Medical Care ______ ______ Assistance obtaining disability benefits___________ ______ Assistance obtaining death benefits__________ I______Assistance obtaining veteran's benefits_______________ 1 Other (write in) May we contact you for further information or to offer assistance? Please list methods of contact, _________________ Phone number including area code________________ ¡Email if available______________ ______ Comments: Continue on another sheet of paper if necessary. | Yes No Yes j No 1 Yes No [Please return to Sharmon Cook-Wright at P.O. Box 549, Siletz, OR 973 80-0549 or to an area office by Feb. 1. Thank you. ¡Call Sharmon if you have any questions at 541-444-8213 January 2010 • Siletz News • 9
