Readiness Assessment Survey

ADRC Readiness Assessment Survey

Step 1 – Provide Background Information and Create a Password

This section asks you to provide background information about your organization. It also asks you to create a password which will be unique for your survey – to ensure confidentiality and to enable you to save your work and return to the survey at a later time if necessary.

The information you provide in this section, together with the responses you provide to the survey questions in Step 2, will be used to create a customized ADRC Readiness Profile for your organization.

The information provided in this assessment will be kept strictly confidential. Your responses and profile results will be password protected and will not be accessible without the password.

Please provide background information about your organization:

ID/Tracking #: 1337256616

Date: 5/17/2012 8:10 am

1. Name of the organization to be assessed:

2. The current status of the organization:

Check one:

Existing ADRC, operated by a state level organization

Existing ADRC, operated by a local level organization

Organization planning/considering becoming ADRC (state level organization)

Organization planning/considering becoming ADRC (local level organization)

3. Type of organization:

Check all that apply:

Public sector (agency or department)

Private, non profit organization

Private, for-profit organization

AAA

SUA

Other aging services organization or agency

CIL or SILC

Other disability services organization or agency

2-1-1/I&R

SHIP

Medicaid agency

Social Services Agency

Other (Specify):

6. Name of person completing the assessment:

7. Title of person completing assessment:

8. Contact information: e-mail (You will use your e-mail address to log into the site if you need to come back to it. Also, your results for the survey will be sent to your e-mail address)

Please Create a Password:

Please Re-enter Password:

You will need your password if you wish to leave the survey and return to it where you left off at a later time, if necessary. You will also need your password to access the ADRC Readiness Profile when it is sent to you after you have completed and submitted the survey.

Review

Before leaving this section be sure to review the background information you provided to make sure it is accurate and complete. All fields are required.