Safe, Respectful & Accessible Needs Assessment Break-out Session Louisville 2007 Grantee Meeting May 20, 2008, 3:30 – 5:00 p.m. Just ASK – Kansas Collaboration Just ASK Needs Assessment Plan Appendix D.5 Invitation to the Individuals with Disabilities Focus Group Possible language for CIL or SA/DV Advocate when extending an invitation to a consumer/survivor We're going to be working with our local (Center for Independent Living or Sexual Assault/Domestic Violence organization) to find survivors and people with disabilities to participate in focus groups. We want to find out how we can better provide services to survivors with disabilities. I thought you might be interested in helping us. The focus group will be on (date) at (time) and last about 90 minutes. We can help with several things - transportation, childcare, interpreters, or other accommodations. We'll just need to know a little ahead of time. Various focus group and interview times are available. Please check the time/date most convenient for you. Here's an RSVP form and an envelope to return it if you choose to participate or you can just call me and we can fill the form out together. If you have any questions, please let me know. __________________________________________________ Please see the following if an individual requests any accommodations or information. Information on transportation: (will be community specific) Just ASK has purchased bus tokens/ transit vouchers. They are available at the CIL or SA/DV office for staff to give to potential focus group participants. Information on childcare: (will be community specific) Volunteers from______ will be in a room next door to the focus group location. They will be playing a movie and have crafts & games available. Commonly requested accommodations Information on alternate PCAs: (will be community specific) Alternate PCAs are being provided through _____. We request specific information about the kinds of PCA services needed to ensure we have a qualified PCA acting as an alternate. Examples of services needed might include scribe or assistance toileting. ASL - American Sign Language for people who are deaf or hard of hearing and use ASL as their language OTHERS - Foreign languages, SEE/ Sign Exact English (some mainstream school systems use this for students who sign), languages for people who are deaf/blind BRAILLE - for people with visual impairments or are blind, tactile format LARGE PRINT - for people with low vision AUDIOTAPE - for individuals who prefer to read through the use of recorded audiotaped information CD - for individuals who prefer to review text documents via computer PERSONAL CARE ATTENDANT - an individual that assists a person with a disability perform tasks where assistance is required CHEMICAL SENSITIVITY - awareness that the presence of chemicals in the environment may present significant barriers to some individuals resulting in a commitment to be as scent-free as possible PHYSICAL ACCESS - this relates to the architectural access of a building or room and is in reference to individuals with disabilities related to mobility (for example, someone who uses a wheelchair, a walker, a cane) DIETARY CONCERNS - some individuals may have food allergies. Other considerations may include low sodium, low sugar, gluten-free, etc. Safe, Respectful & Accessible Needs Assessment Break-out Session Louisville 2007 Grantee Meeting May 20, 2008, 3:30 – 5:00 p.m. Just ASK – Kansas Collaboration Just ASK Needs Assessment Plan Appendix D.6 Individuals with Disabilities Focus Group RSVP Form If you are attending a focus group or would like to have an interview, please return this card to your local center for independent living at (actual name and address) or SA/DV organization at (actual name and address) or call (telephone numbers) to let us know how we can make the focus group accessible for you. All information provided is confidential. Name: __________________________________________________ City: ___________________________________________________ Organization or City where you receive services:_________________ I prefer to participate in a (please check one box) Focus Group (please select date/time) ? ____________________ (date/time will be specified) ? ____________________ (date/time will be specified) Individual Interview ? ____________________ (date/time will be specified) ? ____________________ (date/time will be specified) Just ASK will ensure accommodations are available at focus groups & interviews. Please let us know what services you request (check all that apply): ? Transportation ? Child care Number of children and ages: ___________ ? ASL interpreter ? Other language interpreter Please specify: _______________ ? Alternate format for materials (check one) ? Braille ? Large print ? Other Please specify: ____________ ? Alternate Personal Care Attendant Please specify needs:____________________ ? I will have my own Personal Care Attendant ? Dietary concerns for snacks. Please specify:_______________ ? Other Please specify: _______________________ Safe, Respectful & Accessible Needs Assessment Break-out Session Louisville 2007 Grantee Meeting May 20, 2008, 3:30 – 5:00 p.m. Just ASK – Kansas Collaboration Just ASK Needs Assessment Plan Appendix E Focus Group Confidentiality Statement The following statements about confidentiality will be the guidance for the operation of the focus group. Safety of the focus group participants is of primary importance. 1. Stephanie, Jehan and Ann will keep your information private. If you say you will hurt someone or yourself, we cannot keep that private, but everything else will be kept private. Stephanie, Jehan and Ann are not mandatory reporters. 2. Although the moderators are the only members of the group who are bound by confidentiality requirements, we strongly encourage all members of the group to keep the information shared and discussed during the session confidential based on mutual trust, safety concerns and respect for other members of the group. 3. Sometimes it is hard to share your story or ask a question about your situation because you are afraid of being reported to a watchguard agency. If you are uncomfortable talking about yourself, we suggest that you begin your remarks with a statement similar to: “A friend of mine is having this problem.” or “Suppose there were a situation like this: . . .” Then share the story or ask the question. Stephanie, Jehan and Ann are not mandatory reporters. 4. If you chose to privately discuss your situation with a moderator, we want you to know that private discussions with moderators will be held confidential. 5. All information presented and discussed by the group will be used only to plan better services for survivors. 6. No information that can personally identify you will be used in planning; however, we may identify your town in the planning process.