1. Have you ever had in-home help? YES NO 2. If yes, what kind? (Check all that apply) Nurses from an agency. Someone you hired and paid for yourself. Family members only. A state-funded personal assistance (attendant) program. 3. I have had problems with: (Check all that apply) Agency won't give enough hours that I need. Have to conform to agency rules (be in bed at a certain hour, etc.) Do not receive enough funding to pay my attendant adequately. Must rely on family members. Cannot get any program to pay for in-home help for myself. If you have any other particulars you'd like us to know, please tell us about it in 100 words or less. If you need more space, feel free to send us E-mail. 4. Have you ever been part of your state's personal assistance service program? If yes, please tell us about it in 100 words or less. If you need more space, feel free to send us E-mail. 5. Would you be willing to have us contact you for an article? YES NO 6. Optional: NAME PHONE EMAIL

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