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Just ASK Needs Assessment Plan 
Introduction 
In 2006, the Kansas Association of Centers for Independent Living 
(KACIL), the Kansas Coalition Against Sexual and Domestic Violence 
(KCSDV) and the Kansas Department of Health and Environment (KDHE) 
were funded, by a cooperative agreement to KCSDV from the Office on 
Violence Against Women in the Department of Justice, to form a 
collaborative to address sexual assault and domestic violence against women 
with disabilities. All the partners are advocacy organizations in their field, 
and each bring unique contributions to the collaborative based on their 
organization’s focus. KACIL is a state-wide member organization for 
centers for independent living (CILs); KCSDV is a state-wide member 
organization for community sexual assault/domestic violence (SA/DV) 
programs; and KDHE is a state agency which promotes the health of people 
with disabilities. 
The collaboration – formally called Just ASK (Autonomy and Safety 
of Kansas) – has a mission of increasing access points for survivors with 
disabilities, by connecting centers for independent living and sexual assault 
and/or domestic violence program. Once connected, Just ASK will support 
targeted local collaboratives as relationships are formed by promoting 
increased safety and autonomy of survivors through changes in system 
structures, policies, procedures, and environments. To realize this mission, 
Just ASK is conducting a needs assessment with target sites with whom the 
project will be implemented. The needs assessment will then inform the 
development of a strategic plan which will guide our work over the next two 
years. 
This document describes the approach, methods and activities of the 
needs assessment to be conducted with the target sites. The needs 
assessment will allow us to accurately assess the current state of services and 
systems for service delivery for survivors of domestic or sexual violence 
with disabilities in the target sites. It will also inform the strategic plan for 
systems change, collaboration building, improving services for survivors 
with disabilities and improving the capacity of organizations providing 
services. 

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Target Site Selection 
Salina and Wichita were chosen as target sites using a competitive Request 
for Application (RFA) process. The application required a joint application 
by the SA/DV program and the CIL and included a narrative demonstrating 
their willingness to participate in all phases of the grant process. The review 
committee used specific criteria to choose two target sites that embrace 
collaboration building as an avenue to systems change and the 
implementation and use of a needs assessment in this context. The criteria 
included: 
• Experience with collaboration and joint interest in this project. 
Included a Memorandum of Understanding among the 
organizations or letters of commitment from the organizations 
involved. 
• Demonstrated willingness to commit individuals with 
leadership roles from each organization to be engaged in the 
process. 
• Demonstrated willingness to learn and change through 
intensive technical assistance such as the creation of a formal 
charter for the local collaboration. 
• Demonstrated willingness to participate in a needs assessment 
process and the formulation of a strategic plan. 
• Demonstrated willingness to engage in a systematic, detailed 
review and possible change of organization policies and 
protocols to result in sustainable change. 
Both Salina and Wichita expressed strong commitment to long term 
partnerships. Their applications were chosen because they demonstrated not 
only high capacity but also the creativity, excitement and energy necessary 
for this work. Each of the target sites have unique characteristics as well. 
Salina is a semi-urban community with extensive rural outreach including 
satellite offices in Concordia. The Salina CIL is affiliated with the 
community organization for people with developmental disabilities. Wichita 
has a completely urban service area. The sexual assault program and 
domestic violence program in Wichita are separate, stand-alone agencies 
with a solid history of cooperation between them. The needs assessment 
will provide the information to develop a community-specific plans to 
address barriers to access. 

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Goals for the Needs Assessment 
The following goals have been identified for the needs assessment: 
Identify gaps and barriers to services experienced by survivors with 
disabilities when they seek advocacy services from local SA/DV or 
disability advocates. 
Identify the current strengths and assets of local SA/DV programs and 
local CILs currently providing advocacy services to survivors with 
disabilities. 
Identify barriers within SA/DV programs and CILs that discourage 
survivors with disabilities from disclosing violence or discussing a 
disability. 
Identify the elements that contribute to effective co-advocacy between 
local SA/DV programs and local CILs. 
Identify support or assistance that is needed by each target site to 
continue their collaborations and sustain change beyond this project. 
We will use the information gathered through the needs assessment 
process to determine the activities on which we will focus in our strategic 
plan. We anticipate that the information gathered from the target sites will 
have some similarities as well as community-specific differences. Our 
strategic plan will be drafted in a way that recognizes commonalities but 
also accounts for unique differences among communities. 
Existing Data 
Examining existing data can inform the needs assessment by helping 
to narrow the focus of what is to be addressed in various needs assessment 
tools, determine the scope of the various populations, and inform the 
recruitment strategies. Existing data sources have been identified. They 
include, but are not limited to, sources listed below. 
1. The Just ASK collaboration Feedback Project. The collaboration 
requested information from six sites on their experience when they 

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participated in the previous violence and disability grant. This information 
will be used to inform the questions to be used for the interviews, focus 
groups, surveys and the needs assessment report in the development of 
themes. 
2. The U.S. Census Bureau 2000 updated census that provides 2006 
information on total Kansas population, the number and percentage of 
people with disabilities within specific age ranges. These data help to 
inform us on the numbers and distribution of people with disability in 
Kansas. 
3. The 2006 Kansas Behavioral Risk Factor Surveillance System [BRFSS] 
provides data on the number of people in Kansas with a disability, plus 
information on gender, household income and population density. These 
data will be used to inform site-specific questions to be used in surveys, 
interviews and focus groups, as well as information about the similarities 
among sites. 
4. Data reported by member programs of the Kansas Coalition Against 
Sexual and Domestic Violence (KCSDV) that gives us numbers on reported 
incidents of sexual assault and domestic violence in Kansas. These data will 
inform us on the numbers and distribution of survivors with disabilities. The 
data also will provide information on the scope of other populations, inform 
the recruitment strategies, and help identify similarities in sites. 
5. The 2005 report from the Kansas Governors Office of Federal Grants on 
individual survivors of sexual or domestic violence who self-identified as 
having a physical or mental disability. These data will inform us on the 
numbers, age and gender of survivors with disabilities, provide information 
on the scope of other populations, inform the recruitment strategies, and help 
identify similarities in sites. 
Methodology 
The methodology to be used in implementing the needs assessment 
will have some similarities across the target sites. The organizations and 
individuals within organizations will be the same, that is, SA/DV programs 
and CILs and their board members and staff will be included; the kind of 
tools used, but not the content, will be the same, e.g., focus groups will be 

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used at all three sites; and the format of conducting interviews and focus 
groups will be the same across both sites. 
A. Organizations 
The RFA process which was used to identify the target sites required 
the application to be signed by all organizations who have agreed to be part 
of the collaboration. In Wichita we will be working with Harbor House, a 
domestic violence program, the Independent Living Resource Center 
(ILRC), the independent living center, and the Wichita Area Sexual Assault 
Center (WASAC), the sexual assault center. In Salina we will be working 
with the Domestic Violence Association of Central Kansas (DVACK), a 
domestic violence and sexual assault crisis center, and Independent 
Connection, the independent living center. These are the primary 
organizations with whom we will work to implement the needs assessment. 
B. Populations and Tools. 
The needs assessment will focus on services to survivors with 
disabilities, and, therefore, will focus on SA/DV and CIL services. Target 
sites have committed to the needs assessment and understand what groups of 
individuals will participate. Four groups of individuals from SA/DV and 
CIL organizations can provide information that is useful to the needs 
assessment. 
1. Boards of Directors. Boards of Directors are key to providing the 
policy support and commitment of resources that are necessary for 
sustaining change. A paper or electronic survey will be sent to all 
members of boards of directors of the SA/DV program and the 
CIL. The survey focus will be to assess current service capacity, 
barriers and supports to systems change, gaps in services and 
access points. 
2. Executive Directors. The Executive Director’s leadership is 
crucial to creating and sustaining systems change within an 
organization. Personal interviews will be conducted with the 
executive director of each organization. The interview focus will 
be to assess current service capacity, barriers and supports to 
systems change, gaps in services and access points. 

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3. CIL Staff and SA/DV Advocates. Direct service staff and 
advocates are the critical source to understand gaps between policy 
and practice. Direct service staff and advocates will be invited to 
participate in focus groups to assess points of access, comfort 
levels and gaps in service. Separate focus groups will be held for 
CIL staff and SA/DV Advocates. 
4. People with Disabilities. People with disabilities are the most 
important source of information in evaluating current advocacy 
and in conceiving of services that fully address safety and 
accessibility. Focus groups will be held for people with 
disabilities, with a brief check-in for each individual at the 
beginning of the group session. 
To the extent that the focus group maximum of 8 persons limits the 
diversity of survivors, the number of staff and advocates who are willing to 
participate, or the inclusion of other community agencies, additional focus 
groups will be organized and facilitated. 
The minimum projected number of participants for each population 
are: 
Population Minimum Participants at each 
Target Site 
Wichita Salina 
Boards of Directors 3 survey groups 
WASAC: 10 
Harbor House: 10 
ILRC: 15 
2 survey groups 
DVACK: 8 
Independent 
Connection: 12 
Executive Directors 3 interviews 
WASAC 
Harbor House 
ILRC 
2 interviews 
DVACK: 
Independent 
Connection 
Staff & Advocates 3+ focus groups 
WASAC: 8 
Harbor House: 8 
ILRC: 8 
2+ focus groups 
DVACK: 8 
Independent 
Connection: 8 
PWD 20+ participants 20+ participants 
including at least one in 
rural Cloud County 

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To the extent that CIL staff, SA/DV advocates, survivors and people with 
disabilities wish to contribute but are hesitant or unable to participate in a 
focus group, we will accommodate them with an interview process. 
C. Recruitment 
As stated, organizational willingness to participate with needs 
assessment activities was demonstrated by programs through the RFA 
process. Recruitment for specific groups is as follows: 
1. Boards of Directors 
The Executive Directors of the target site CIL and SA/DV programs will 
be asked to identify the individuals to receive the survey. Board 
members will receive the survey with an explanation of 
the purpose and how their participation will inform the process. 
2. Executive Directors 
The Executive Directors of the target site CILs and SA/DV programs will 
participate in an interview. The scheduling call will explain the 
purpose of the interview and how it will inform the process. 
3. CIL Staff and SA/DV Advocates 
The local CIL and SA/DV programs will be asked to issue information to 
staff and advocates about participating in the focus groups. There will be 
a minimum of two focus groups, one each for CIL staff and SA/DV 
advocates. Depending on response and timing, several groups could be 
held for both CIL staff and SA/DV advocates. A local program primary 
contact will collect RSVPs from interested staff and advocates and submit 
to Just ASK. 
4. People with disabilities 
• Recruiting for the people with disabilities focus group will be a 
cooperative effort between Just ASK and the target site programs. The 
primary recruitment strategy will be direct invitations from CIL and 
SA/DV program staff to people with disabilities. CIL and SA/DV 
program staff will share information regarding the focus group and 
collect RSVPs from interested individuals. 
• A secondary strategy will be notification via more informal existing 
networks as they are identified by local CIL and SA/DV program 

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staff. Those existing networks may include publication in newsletters 
and email listservs to announce the formation of the focus groups and 
how individuals can get involved. We will not be using flyers. 
• RSVP’s (see Appendices C.3 and D.6) will be requested to allow us to 
prepare for alternative formats, interpreters, transportation, childcare 
or other needs. RSVPs will be directed to the local CILs and SA/DV 
programs. The form for taking RSVP information will be furnished to 
the local programs. The staff will then funnel the RSVPs to Just ASK 
to make the needed arrangements. 
D. Survey, Interviews and Focus Group Facilitation 
Data to be gathered for use in strategic planning with the target sites will 
come from the sources as described above. The data collection process of 
surveys, interviews and focus groups will be facilitated as described in this 
section. Any needs assessment plan must reflect issues of confidentiality, 
safety needs and accessibility needs. Just ASK has created a plan that 
accounts for these issues on an individual basis as well as in the structure of 
tools and facilitator roles. Participation in a needs assessment carries certain 
risks for both organizations and for individuals. Just ASK will collect 
information in ways which respect confidentiality for individuals and target 
sites. We will also ensure a process that respects the reputation of the 
community and creates an environment conducive to change. 
1. Boards of Directors Survey 
The survey for the Boards of Directors will be administered to the board 
members of the target site CILs and SA/DV organizations with the 
assistance of the Executive Directors. The survey will be offered in paper, 
electronic or other alternative format as requested. The needs assessment 
facilitators will confer with the Executive Directors of each organization 
about the most efficient manner in which to contact them, i.e., electronically 
or other method. 
A cover letter (see appendix B.1) explaining the program and the 
purpose will accompany the survey. The electronic survey will be checked 
for accessibility and its compatibility with screen readers. The electronic 
version will be submitted electronically to the needs assessment facilitators; 
the Executive Directors will facilitate submission of the survey in other 

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formats to Just ASK. It is anticipated that the survey will take 10 to 15 
minutes to complete. 
2. Executive Director Interviews. 
The Executive Directors of the target sites CILs and SA/DV programs 
will be invited to participate in an interview. The needs assessment 
facilitators will issue the invitation by telephone with an explanation of the 
purpose, the time involved and the importance of their participation. A date 
and time for the interview that is mutually acceptable will be scheduled 
during the call. The interview will be conducted by one or more of the three 
Co-Directors at the Executive Director’s office or other location preferred by 
the Executive Director. It is anticipated that the interview will take 1 to 1 ˝ 
hours. 
3. Facilitation of Focus Groups 
Focus groups will be conducted for direct service advocates and staff at 
CILs and SA/DV programs. We will also conduct focus groups of 
survivors/people with disabilities. Our structure will be largely consistent 
across each type of focus group. 
We will ensure universal access to focus groups and surveys, including 
groups being scent free, and attend to each participant’s need for safety. We 
also will ensure that groups represent the diversity of the target 
communities. Our commitment to confidentiality will be stressed at the start 
of each group. Every focus group participant will get a copy of our 
confidentiality statement and the statement will be displayed on a wall in the 
room. 
Each focus group will be facilitated by the three Just ASK codirectors
. The roles of the facilitators for the focus groups will be divided as 
follows: 
Moderator. The moderator will facilitate the large group 
discussion and attend to the environment of the group. This 
includes opening and closing the group and maintaining the focus 
of the discussion. The moderator is also responsible for 
maintaining a space where all participants have a true opportunity 
to contribute. This is especially crucial in a group where the topics 
may be difficult to discuss and group members may utilize 

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different modes of communication. The KACIL co-director will 
be the moderator. Her expertise comes from conducting focus 
groups discussing difficult topics such as disability, moderating 
training sessions, teaching at a post-secondary level, and providing 
direct service to people with disabilities and survivors. 
Recorder. The recorder will take notes, recording responses as 
accurately as possible. The recorder will not only record spoken 
comments but will also note observed communication such as 
topics which present particular frustration or hesitancy. All 
participants will be informed that while direct quotes may be 
utilized in the report, no participant will be identified in any way 
(confidentiality, section F). The KDHE co-director will be the 
recorder. Her expertise is based in a thorough understanding of the 
need for accuracy and gathering focus group information as 
objectively as possible if it is to be of use in informing the needs 
assessment report and the strategic plan. 
Floater. The third facilitator’s primary role is to be responsive in 
the face of a participant’s crisis or distress. If a participant begins 
to feel overwhelmed, wishes to talk individually or needs to leave, 
the floater will check-in with them in a private space. The floater 
has a secondary role as assisting with large group facilitation if no 
one presents an individual need. The KCSDV co-director will be 
the floater. Her experience as a direct service advocate for DV/SA 
survivors gives her the expertise be responsive to a participant’s 
crisis or distress. 
Each group will be limited to 8 participants. This small number will 
enhance our ability to create space for all participants and will ensure that 
individual needs can be addressed. 
The groups will be specifically tailored for each audience as detailed 
below. 
Staff/Direct Service Advocates Group 
As they arrive, participants in the staff and direct service advocates 
group will be given a brief demographic survey (Appendix C.1) to complete 
as well as a list of the discussion questions for their reference. Demographic 
information is being gathered to ensure equal representation of advocates 

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across programs (SA outreach, DV outreach, CIL outreach). All 
demographic information will be destroyed no later than 3 months following 
the completion of the strategic plan. The moderator will conduct a 60 
minute (approx.) discussion focusing on specific questions (Appendix C.2). 
The final 10 minutes of the group will be question and answer (Q&A) and 
wrap-up. At the conclusion of the focus group, a box will be available for 
participants to anonymously contribute program and demographic surveys. 
Staff and advocates may have safety needs that impact their participation. 
We will offer individual interviews for staff and advocates who feel unsafe 
or uncomfortable participating in a group setting. Facilitators are also 
available after the group for anyone who has an emerging safety concern. 
People with Disabilities Group 
The focus groups for people with disabilities will include a brief 
check-in with each individual before the beginning of the group. All three 
facilitators will participate in the check-in procedure. The check-in will be 
used to explain who we are, expectations about the focus group, inquire 
about the individual’s level of comfort and safety in participating, 
confidentiality expectations, and the demographic information to be 
gathered. Demographic information is being gathered to ensure equal 
representation of across programs (main office, satellite office). All 
demographic information will be destroyed no later than 3 months following 
the completion of the strategic plan. 
a. Each focus group will have a 20 minute check-in period for 5 minute 
individual interviews, a 60 minutes group discussion, and a 10 minutes 
question and answer (Q&A) and wrap up. 
b. During check-in, each participant will receive a demographics survey 
form (Appendix D.1), a confidentiality statement (Appendix E), a 
statement of our role/purpose (Appendix D.2), discussion questions for 
the focus group (Appendix D.4), and contact information for local CIL 
and DV/SA organizations. Participants also receive a SASE to the 
KDHE co-director, which will have no reference to SA or DV, in 
which they can mail in additional thoughts after the discussion. 
c. Each participant will be given a stipend for their attendance. 
d. Facilitators will take a brief moment after initial interviews to check in 
with each other. Participants will use this time to get comfortable, 
have a cup of coffee, look over discussion questions, jot down ideas, 
etc. 
e. At the conclusion of the focus group, a box will be available for 
participants to anonymously contribute the demographic surveys. 

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f. Each participant will have an opportunity to check-in individually at 
the conclusion of the group to address any emerging needs. 
4. Facilitation of Interviews with Individuals Unable to Participate in Focus 
Groups. 
Individuals may be interested in participating in focus groups or 
contributing to the process but are unable to participate because of 
schedules, preferring to communicate individually, safety concerns or other 
reasons. Interviews will be arranged with these individuals at an agreed 
upon date and time. If at all possible, the interviews will be arranged while 
the facilitators are at the target site. The interview process is anticipated to 
take 45 minutes to 1 hour, and will use the focus group discussion questions. 
All facilitators will be scent-free for the interviews. 
E. Research Tools 
1. Tool development 
Just ASK developed several tools that will be used in the needs 
assessment process to collect and record the data as described in the 
methodology section. The specific tools are contained in the appendices 
(see Appendices Table of Contents, p. 18). They will be used with different 
target groups as follows: 
• Survey (paper, electronic and other alternative formats): Members of 
the Board of target site CILs and SA/DV organizations. 
• Interviews: Executive Directors of target site CILs and SA/DV 
organizations; staff, advocates, and people with disabilities who are 
unable to schedule participating in focus groups. 
• Demographic survey: target site CIL staff and SA/DV advocate focus 
groups or individual interviews, and people with disabilities focus 
groups or individual interviews. 
• Focus group questions: target site CIL staff, SA/DV advocates, and 
people with disabilities focus groups. 
Additional documents to be used with the groups include a 
confidentiality statement, a Just ASK statement of purpose and roles, a cover 
letter for members of the Boards of Directors of each organization 
explaining the purpose of the survey, and an RSVP form. 

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Facilitation of the needs assessment is explained in Section D of this 
plan. All documents will be in accessible formats as needed. Appropriate 
support will be available for focus group participants who do not read or 
process written language. See full safety and accessibility protocols on pp. 
13 – 16. 
F. Confidentiality 
Just ASK is highly committed to maintaining confidentiality for 
participants in our needs assessment. Just ASK co-directors are not 
mandatory reporters according to Kansas Statutes. We have crafted a 
confidentiality statement (Appendix E) to ensure that all participants 
understand our confidentiality protections. This statement also outlines 
potential risks participants may still face if disclosing (such as a fellow focus 
group member not maintaining confidentiality). We have structured 
multiple ways to emphasize confidentiality and to explain our expectations 
and limits. We will: 
• Discuss confidentiality with each individual at brief one-on-one 
interviews before each focus group; 
• Explain the confidentiality statement to the group; 
• Have a large copy of the confidentiality statement on the wall so 
it is present in the room during the group; and 
• Provide a copy of the statement in the participant’s desired 
format so it can be reviewed later if there are concerns. 
To help limit potential risks, we are also giving any focus group 
participant private and/or anonymous ways of communicating with us. 
These include the brief one-on-one meetings before group, a box for 
collection of demographic survey information, the opportunity to meet with 
a facilitator privately after group, or to schedule a private interview instead 
of participating in a group. 
We are also attending to a high level of confidentiality within Just 
ASK. No identifying information will be revealed in the needs assessment 
report about individual focus group or interview participants. Any 
politically sensitive information about organizations gathered during the 
needs assessment will be held strictly confidential and used only for strategic 
planning purposes. All documents used to record information will be 
destroyed no later than 3 months following the completion of the strategic 

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plan. All data will be stored at a secure site within KDHE. Only Just ASK 
co-directors will have access to this information. 
Safety Planning and Accessibility Protocols 
A. Safety Planning 
People with disabilities who are survivors of sexual assault or domestic 
violence may face a variety of potential risks in participating in this needs 
assessment. Just ASK recognizes that safety for survivors of violence 
requires consideration of risks a survivor faces by virtue of social/cultural 
factors, as well as risks presented by a perpetrator. A survivor may face 
risks from a community that stigmatizes people with psychiatric disabilities. 
That same survivor may also face risks from a perpetrator who hides her 
medication. The methodology for the needs assessment was carefully 
crafted to minimize safety risks; however Just ASK recognizes that no 
amount of planning can eliminate all the potential risks a needs assessment 
participant may face. 
Given the potential risks, Just ASK is relying on a three dimensional 
safety strategy. We will disclose possible risks to every participant, present 
options to manage these risks and, most importantly, we will listen to the 
survivor. She is in the best position to assess her own safety or comfort 
level and make a decision about participation. 
It is our plan to create an environment that addresses common risks 
survivors may face. We will also create space for one-on-one safety 
planning to respond to individualized risks survivors may face. Key to this 
plan is to offer a choice in how individuals participate—via individual 
interview or through a focus group. It is our hope that this combination of 
generalized planning for safety and individualized response will minimize 
potential harm for participants. 
Just ASK will work with local programs to ensure the location of the 
focus group contributes to a feeling of safety for participants. We recognize 

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that additional risks may be faced by individual participants. Our strategies 
to enhance safety include the following: 
• Risks may be present for staff/advocates or consumers/survivors 
in disclosing unflattering information about the local agency. 
Strict adherence to confidentiality will reduce this risk. Just 
ASK will work with the local agencies on the intent and purpose 
behind the needs assessment. This will hopefully facilitate an 
environment welcoming of critical feedback and minimize the 
potential risk. 
• Survivors may face risks to their emotional safety by 
participating in a discussion that addresses violence. The 
individual interviews before the group begins will help prepare 
survivors for their participation in the group. We will help 
survivors assess their safety level in sharing with the group and 
identify resources available if additional support is needed after 
group. 
• Survivors may be in immediate danger from a perpetrator. 
Again, individual interviews will include safety planning of 
risks. If a survivor reveals s/he is in immediate danger, the 
“floater” facilitator will respond with safety planning and offer 
immediate connection to local resources. 
• A survivor living in a group environment (shelter or otherwise) 
may face risks in disclosing an active addiction or psychiatric 
disability. Confidentiality and safety planning during the 
interview will provide a level of protection for a survivor 
making such a disclosure. 
• A survivor may attend the focus group with a personal care 
attendant (PCA) and feel unsafe disclosing because of the 
PCA’s presence either because of concerns about confidentiality 
or because the PCA is the abuser. Just ASK will offer to 
provide alternate PCAs. Because this option may be restricted 
by an abuser, we emphasize that a survivor can choose not to 
answer or respond to any questions that make them 
uncomfortable. To address concerns about privacy all PCAs 
who are present at the focus group or interviews will be asked to 
sign a confidentiality agreement. 
• A survivor/person with a disability may be concerned about 
transportation to or from the focus group. Just ASK will 

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coordinate with local programs to ensure transportation is 
available to participants. 
• A survivor/person with a disability who is a parent may be 
concerned about the care of their children while they attend the 
focus group. Just ASK will coordinate with local programs to 
provide childcare parallel to the focus group. 
• Some survivors may face risks from a perpetrator if they were to 
return home with unexplained money or giftcards. Just ASK 
will have stamped envelopes available to mail the stipend to a 
safe mailing address for any survivors who are unsafe bringing 
the stipend home. 
B. Accessibility 
Just ASK collaboration is committed to full accessibility for survivors with a 
disability. 
• Needs Assessment Tools: Just ASK will ensure alternative formats are 
available for all of our tools. Our survey, interview and focus group 
tools will undergo review with a committee of disability experts to 
check for readability and appropriate language use. The survey for 
board members will be available in hard copy in a variety of formats 
as well as available on-line in a survey compatible with screen 
readers. Focus group participants will be asked to identify 
accessibility needs prior to the meeting. Just ASK will coordinate 
with the local programs to ensure the availability of a wide range of 
alternative formats. 
• Accessible Communication: Just ASK will coordinate with local 
programs to ensure documents are translated into appropriate 
languages and to ensure that interpreters are available as requested. 
• Location of the focus group: Just ASK will solicit recommendations 
for focus group locations from the local programs. We will also 
conduct site visits to ensure the room is easy to access for all people 
(checking the level of strength required to navigate the doors, the ease 
with which a participant could go from the front door to the room or 
to the bathroom, sufficient accessible parking, etc.). 
• Chemical sensitivity concerns: Just ASK will strive to ensure that the 
focus groups are scent-free. The interviews will be scent-free. 

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Compile and analyze data 
Once the needs assessments have been completed with the three sites, 
Just ASK coordinators will compile the data for each site. Using all the 
data collected from existing data sources and the needs assessments, the 
coordinators will identify issues that are common across the target sites and 
issues that are specific to individual sites. 
The full collaborative will then use the analyses to prioritize issues to 
be addressed across sites. A needs assessment report will be developed 
from the collaborative consensus which will be used to inform the strategic 
plan. The strategic plan will be developed from the report of prioritized 
issues. The collaborative also will provide reports to the target sites that 
identify issues, both specific to a site and across sites, that need to be 
addressed by the sites. 

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Timeline & Workplan 
January 2008 
• Submit RFA to OVW for final approval 
• Continue work on needs assessment plan with support from Vera 
February 2008 
• Receive approval of Charter and RFA from OVW 
• Submit RFA to KDHE for approval 
• Continue work on needs assessment plan with support from Vera 
• Distribute RFA to member programs 
March 2008 
• Continue work on needs assessment plan with support from Vera 
• Select and notify target sites 
April 2008 
• Submit needs assessment plan and tools to OVW for approval 
• Coordinate focus groups 
• Orient target sites to the program and collaboration-building 
process 
May 2008 
• Conduct focus groups and interviews (work with local projects to 
recruit pwd and survivors; work with local sites to find locations 
that are safe and accessible; work with local sites to ensure 
universal access of focus group tools, etc.) 
• Conduct surveys 
• Review other data sources (organization policy, etc.) 
• Write needs assessment report with input from Vera 
June 2008 
• Complete needs assessment report 
• Submit needs assessment report to OVW 
July 2008 
• Site visit from Vera to begin strategic plan process 
• Submit strategic plan to OVW for approval 
• Begin implementation of strategic plan 

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Just ASK Needs Assessment Plan 
Appendices Table of Contents 
Appendix A: Definitions 
Appendix B: 1. Survey Cover Letter for Board Members 
2. Boards of Directors Survey 
3. Interview questions for Executive Directors 
Appendix C: 1. CIL Staff and SA/DV Advocate 
Demographic Information 
2. Focus Group Questions for CIL Staff 
and SA/DV Advocates 
3. RSVP card and response form 
Appendix D: 1. Survivor/People with Disabilities 
Demographics Information Form 
2. Statement of Purpose 
3. Check-in Checklist 
4. Focus Group Questions for Survivor/ 
People With Disabilities 
5. Focus Group Invitation 
6. RSVP card and response form 
Appendix E: Focus Group Confidentiality Statement 
Appendix F: PCA Confidentiality Agreement 

20 
Just ASK Needs Assessment Plan 
Appendix A 
Definitions 
The definitions in this appendix are for readers of the needs assessment plan 
and will not be used with individuals or groups participating in the needs 
assessment. 
• Accessibility: People with disabilities have the right to an equal 
opportunity to participate in the community including employment, 
accessing government programs, public accommodations, 
transportation and communication. Accessibility means that disability 
is accounted for in all aspects of life and that structures, processes and 
environments are designed to maximize inclusivity. 
• Advocacy: Broad term to describe actions directed by and on behalf 
of marginalized individuals to support their autonomy, to influence 
systems and to educate communities. Survivor-centered advocacy 
uses a framework that is responsive to the survivor as a whole person 
by acknowledging risks generated by the perpetrator, systems and 
society. It includes a philosophy where survivors are valued as the 
experts, where each survivor’s individual experience is the starting 
place for action. When using the term “advocacy”, Just ASK includes 
wide ranging activities such as intakes, telephone calls, in-person 
support, information sharing, referrals, peer-support, safety planning 
and transportation. 
• Autonomy: Every individual’s inherent human right to direct their 
own destiny, make choices and to define their own experiences. 
• Collaboration: A conscious and dynamic relationship made by two 
or more organizations with formalized agreements to share influence 
and resources in order to achieve mutually beneficial results they 
could not achieve individually. (This definition is based heavily on 
work by the Fieldstone Alliance.) 
• Confidentiality: Creating deliberate protections for information that 
is given to an individual or to an organization with the expectation 
that the information is not shared without specific permission from the 
individual who owns the information. 

21 
• Disability: To meet the ADA definition of disability a person must 
have a physical or mental impairment that substantially limits a major 
life activity, has a record of such an impairment or is regarded as 
having such an impairment. An emerging definition of disability 
focuses on the environment as a barrier, rather than a person’s 
functional limitations. This environment can include the 
social/political, informational, communication as well as the physical 
environment. People with disabilities are also a cultural group and 
constitute the nation’s largest minority. This group is simultaneously 
inclusive and diverse crossing all ages, religions and ethnic groups, 
socioeconomic levels, genders and sexual orientations. 
• Diversity: A recognition of the infinite number of ways there are to 
be human and to move through the world. Diversity is an 
acknowledgement of differences in identity, background, history, 
experiences and options. There is often a focus on gender, disability, 
race, economic background, religion, sexual orientation or rural/urban 
issues. This collaborative’s definition includes these but also other 
elements and recognizes the multiple ways people can identify within 
each group. 
• Domestic violence is a pattern of abusive and coercive behavior used 
to establish power and control over another person through fear and 
intimidation. Domestic violence occurs within intimate relationships, 
and abusers can be spouses, partners, boyfriends/girlfriends, family 
members, or caregivers. Batterers take away the victim’s fundamental 
right to maintain control over their own lives. They do this by using 
various abusive tactics including use of violence and threats of 
violence, controlling the victim’s mobility, isolating the victim, 
threats to hurt the victim and the victim’s family, controlling the 
victim’s money and using fear, intimidation and shame to silence the 
victim. 
• Points of Access: Any place, contact, document or information which 
leads a survivor or person with a disability directly to services from a 
CIL or SA/DV program. Points of access may include a variety of 
opportunities for contact between an individual and the organization 
such as outreach materials, a person in the community who 
recommends an advocate, a website, a community event that 
highlights services or heightens awareness, a mechanism in an allied 
system that makes automatic referrals, etc. The survivor or person 
with a disability may make contact via telephone, in-person, attend a 
group meeting, email, etc. 

22 
• Safety: An environment that attends to the physical, emotional and 
spiritual needs of each individual, thereby allowing them to exercise 
their autonomy. 
• Sexual Assault: Any type of sexual activity to which a person has not 
freely consented. It is a form of violence that uses sex and sexuality 
to humiliate, intimidate, control or instill fear in another person. 
Sexual assault can be committed by the use or threat of force or under 
circumstances where a person is incapable of consenting. It ranges 
from intimidation to inappropriate touching to penetration or 
intercourse. It also can be verbal, visual, audio, or any other form 
which forces a person to participate in unwanted sexual contact or 
attention. Sexual assault includes rape and attempted rape, child 
molestation, voyeurism, exhibitionism, incest, and sexual harassment. 
It can happen in different situations, such as date rape, personal 
assistant or domestic or intimate partner violence, or by a stranger. 
• Systems Change: A method of impacting the culture of an 
organization by focusing on the structures, policies and procedures of 
the organization. This results in a sustainable shift in attitudes, 
practices and services provided by that institution. 
• Technical Assistance: The proactive provision of prescribed or 
requested specialized support, help and information on specific topics 
or activities. It may be delivered in-person, by telephone, 
electronically or in writing. The assistance is provided in a timely, 
specific, respectful and thorough manner. 

23 
Just ASK Needs Assessment Plan 
Appendix B.1 
Survey Cover Letter for Board Members 
Dear (Name): 
Thank you for participating in the needs assessment survey about the services 
your organization provides to people with disabilities who are survivors of domestic or 
sexual violence. As you know, your organization is part of a local collaboration that was 
chosen as a target site to be part of a grant to enhance and increase services to survivors 
with disabilities through systems change. Your collaboration was chosen, in part, 
because of the commitment to change and the willingness to participate in all phases of 
the change process. The grant provides a variety of benefits to your collaboration that 
will be provided by Just ASK, a collaboration of the Kansas Association of Centers for 
Independent Living (KACIL), the Kansas Coalition Against Sexual and Domestic 
Violence (KCSDV), and the Kansas Department of Health and Environment (KDHE). 
One of the first benefits to your community collaboration is a needs assessment. 
Your participation as a board member in the needs assessment board survey is 
very important to the process. You are in a unique position to provide a broader view of 
the community, your organization and its resources. You are also key to providing the 
policy support and commitment of resources that are necessary for sustaining change that 
increases services to survivors with disabilities. Once the needs assessment is complete, 
we will furnish you with a report, and your community will participate in a strategic 
planning process that will map out how Just ASK will provide technical assistance in 
your community. 
Thank you for your participation in the needs assessment process. If there are any 
questions, please contact one of the Just ASK coordinators by phone or email. 
Sincerely, 
Jehan Faisal Ann Branden Stephanie Sanford 
Co-Director Co-Director Co-Director 
Just ASK KCSDV Just ASK KDHE Just ASK KACIL 
634 SW Harrison 1000 SW Jackson 214 SW 6th Street 
Topeka, KS 66603 Topeka, KS 66612 Topeka, KS 66603 
785-232-9784 785-296-7818 785-550-4808 
jfaisal@kcsdv.org abranden@kdhe.state. ssanford@pilr.org 
ks.us 

24 
Just ASK Needs Assessment Plan 
Appendix B.2 
Board of Directors Survey 
______________ (insert program name) 
Instructions: Please check the appropriate box to answer questions 1-5. 
Questions 6 and 7 are short answer format. 
1. How would you assess your agency’s current capacity to serve 
people with disabilities who are experiencing domestic or sexual 
violence? Consider policies, procedures, attitudes, equipment, 
knowledge, skills, funds and training. 

 We currently have a high level of capacity. 

 We currently have a good level of capacity. 

 I’m not sure 

 We currently have a limited level of capacity. 

 We currently have a low level of capacity. 
Please explain: _______________________________________ 
2. Do you see work to end violence against survivors with disabilities as 
crucial to your organization’s mission statement? 

 Yes 

 I’m not sure 

 No 
Please explain: _______________________________________ 
3. Do you believe current policies and procedures are consistent with 
providing effective service to survivors with disabilities? 

 Yes 

 I’m not sure 

 No 
Please explain: _______________________________________ 

25 
4. What are the three most critical areas in which change is needed? 
(check only three) 

 Budget line items for safety & 
accessibility needs 

 Effective outreach 

 Intake procedures 

 Offer of accommodations re: 
disability 

 Physical structures 

 Policies re: batterer’s 
interference with services to a 
survivor (such as cancelling 
transportation) 

 Policies re: drug or alcohol 
use by survivors/consumers 

 Policies re: personal care 
attendants in shelter 

 Policies re: prescription 
medications 

 Policies re: service animals 

 Protocol for disclosures of 
violence 

 Protocols for utilizing 
interpreters/translators 

 Protocols when both a victim 
and a perpetrator are receiving 
services (for example, attending 
a community event) 

 Provision of alternative 
formats 

 Provision/use of assistive 
technology (TTY, screen 
readers, shower chairs etc.) 

 Referral protocols 

 Screening for sexual 
assault/domestic violence 

 Staff development protocols 

 Workplace violence policy 

 Other (please specify) ______________________________ 
5. Which areas do you consider the most likely in which change to 
improve service for survivors with disabilities could be successfully 
made and sustained? 
(check all that apply) 

 Budget line items for safety & 
accessibility needs 

 Effective outreach 

 Intake procedures 

 Offer of accommodations re: 
disability 

 Physical structures 

 Policies re: batterer’s 
interference with services to a 
survivor (such as cancelling 
transportation) 

 Policies re: drug or alcohol 
use by survivors/consumers 

 Policies re: personal care 
attendants in shelter 

 Policies re: prescription 
medications 

 Policies re: service animals 

 Protocol for disclosures of 
violence 

 Protocols for utilizing 
interpreters/translators 

26 

 Protocols when both a victim 
and a perpetrator are receiving 
services (for example, attending 
a community event) 

 Provision of alternative 
formats 

 Provision/use of assistive 
technology (TTY, screen 
readers, shower chairs etc.) 

 Referral protocols 

 Screening for sexual 
assault/domestic violence 

 Staff development protocols 

 Workplace violence policy 

 Other (please specify) _______________________________ 
Please answer questions 6 and 7 with 2-3 sentences each. 
6. What challenges do you see to implementing change in the above 
areas? 
7. What allies, partnerships or board member affiliations are available to 
your organization to assist in developing or expanding services to 
survivors with disabilities? 
8. What would you consider “success” in your agency’s ability to serve 
survivors with disabilities? What are your benchmarks to know when 
you have been successful? 

27 
Just ASK Needs Assessment Plan 
Appendix B.3 
Executive Director Interview Questions 
1. What are some strengths of your organization and your community? 
2. What key community resources do you utilize when addressing the issue 
of violence against women with disabilities? 
3. Tell us about a policy change you implemented at this organization that 
was very successful. What did your leadership look like? Were there 
challenges and, if so, how did you overcome them? How did you evaluate 
the change? What sustained it? 
4. Do you have a policy about reasonable accommodations or responding to 
violence? What is your organization’s philosophy or value statement 
regarding your work with survivors with disabilities? 
5. What strategies do you use to respond when key systems/allies are either 
inaccessible or present safety risks to survivors with disabilities? 
6. What strategies does your organization use to reach survivors with 
disabilities? 
7. What services to survivors with disabilities do you think could be 
successfully improved and the changes sustained? 
8. What are the three most critical areas in which change is needed? 
9. Identify key resources your organization would need in order to better 
serve survivors with disabilities. Consider policies, procedures, attitudes, 
equipment, skills, budgets for accessibility and safety needs, knowledge and 
training 

28 
10. What do you need in order to provide excellent leadership in addressing 
safety and accessibility for survivors with disabilities? (such as resources, 
model policies, networking opportunities with other EDs, education etc.) 

29 
Just ASK Needs Assessment Plan 
Appendix C.1 
Staff/Advocates Demographic Information 
Instructions: Please provide the information requested and put the form in 
the box provided on the table when you leave the focus group. None of this 
information will be used to identify you in any way. Please do not put your 
name on the form so that you can remain anonymous. This information is 
being gathered to ensure equal representation of advocates across programs 
(SA outreach, DV outreach, CIL outreach). All demographic information 
will be destroyed no later than 3 months following the completion of the 
strategic plan. 
Organization: ____________________________________ 
Position: ________________________________________ 
City where most work is done: _______________________ 

30 
Just ASK Needs Assessment Plan 
Appendix C.2 
CIL Staff and SA/DV Advocate Focus Group Questions 
1. Tell us about a positive experience advocating for a survivor 
with a disability. (follow up: What was comfortable about that 
experience?) 
2. Tell us about a less positive experience advocating for a survivor 
with a disability.(follow up: What was uncomfortable about that 
experience?) 
3. What are some of the ways survivors with disabilities find out 
about your services? (follow up: Do folks come as survivors/people 
with disabilities or do you find out later that they are experiencing 
violence/have a disability? What do you think makes someone feel 
safe and comfortable enough to disclose violence to you/ discuss 
their disability with you? When folks come to you through wordof-
mouth, are there particular services they’re interested in?) 
4. What are some primary barriers and supports when a survivor is 
disclosing violence or talking with you about her disability? 
(follow up: What are barriers/supports within your own 
organization? How do differences between policy and practice 
impact your advocacy? Consider advocacy interactions with other 
systems.) 
5. What are some gaps in services in your community for 
survivors with disabilities? (follow up: Consider gaps in terms of 
accessibility e.g., attitudinal, physical, communication, etc.. 
Consider gaps in terms of safety: emotional safety as well as 
immediate, physical safety.) 

31 
6. In light of existing gaps in the community, how have you or 
your organization been able to provide services to survivors with 
disabilities? (follow up: What connections have you already made? 
What does advocacy for survivors with disabilities look like in your 
organization? Have you used co-advocacy in providing services to 
survivors with disabilities?) 
7. What would you need in order to provide excellent advocacy 
for a survivor with a disability? (follow up: What do you need from 
your board, your ED, your co-workers, your agency’s structure, 
technical assistance. . .? What do you need from yourself?) 

32 
Just ASK Needs Assessment Plan 
Appendix C.3 
Direct Service Advocates 
Focus Group RSVP Form 
If you are attending a focus group or would like to have an interview, 
please return this card to the primary contact at your organization (include 
names) 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 provide services:_________________ 
I prefer to participate in a (please check one box) 
Focus Group (please select date/time) 
S ____________________ (date/time will be specified) 
S ____________________ (date/time will be specified) 
Individual Interview 
S ____________________ (date/time will be specified) 
S ____________________ (date/time will be specified) 
I request the following accommodations (check all that apply): 
Just ASK will ensure that arrangements for accommodations are made. 
S ASL interpreter 
S Other language interpreter Please specify: _______________ 
S Alternate format for materials Please check all that apply. 
S Braille 
S Large print 
S Other Please specify: ____________ 
S Dietary concerns for snacks. Please specify: ______________ 
S Other Please specify: _______________________ 

33 
Just ASK Needs Assessment Plan 
Appendix D.1 
People with Disabilities Demographic Information 
Instructions: Please provide the information requested and put the form in 
the box provided on the table when you leave the focus group. None of this 
information will be used to identify you in any way. Please do not put your 
name on the form so that you can remain anonymous. Demographic 
information is being gathered to ensure equal representation across 
programs (main office, satellite office) and will be destroyed no later than 3 
months following the completion of the strategic plan. 
I am: S A survivor S A person with a disability S Both 
I live in 

 A rural area (such as Concordia or Ada) 

 A semi-urban area (such as Salina) 

 An urban area (such as Wichita) 
I access services at: _______________________________ 
(organization or city) 

34 
Just ASK Needs Assessment Plan 
Appendix D.2 
Statement of Purpose 
Thank you for coming to the Just ASK focus group or interview. 
Just ASK: Autonomy and Safety of Kansas is a group made up of three 
agencies that work statewide. 
• Stephanie works for the Kansas Association of Centers for 
Independent Living, also called KACIL. KACIL works with 
independent living centers from all over the state. 
• Jehan works for the Kansas Coalition Against Sexual and Domestic 
Violence, also called KCSDV. KCSDV works with rape crisis centers 
and domestic violence programs from all over the state. 
• Ann works for the Kansas Department of Health and Environment, 
also called KDHE. KDHE works to promote the health and well 
being of all Kansans. 
We work all over the state and so we do often work with the _____ (name of 
CIL) and _____ (name of SA/DV program.) We do not work for them but 
are here to help them find ways of improving their services. Your input will 
help us do that. The things you tell us will stay confidential. We will tell 
them about the things discussed in the group but will not tell them who 
attended or what they said. 
This meeting is so we can learn more ways to help people with disabilities 
and survivors of violence. 
We will listen to you carefully. You know the community best and know 
the most about what things need to change. 
It is okay to tell us about what services work well in your community and 
what has not worked well. It is also okay if there are things you don’t want 
to tell us. 
If you know of a complaint about a local program, it is okay to tell us. We 
cannot fix the situation but hearing about it may help us understand 
problems that happen all across Kansas. 

35 
Your knowledge is very important. Thank you for sharing it with us. 
Stephanie, Jehan and Ann 

36 
Just ASK Needs Assessment Plan 
Appendix D.3 
Check-in Checklist 
• Welcome and thank the individual for participating 
• Hand the individual the stipend 
• Confirm universal access of focus group or interview 
o On your RSVP you stated we should have ________ (Braille, 
large print, interpreter, childcare, etc.) Does what we have meet 
your needs? Is there anything else that might make you more 
comfortable participating? 
• Explain who Just ASK is 
o Stephanie, Jehan and Ann do not work for the local programs 
and will not share identifying information with them. The local 
programs will get a copy of a report at the end of the needs 
assessment. 
o Stephanie, Jehan and Ann do not make reports to SRS. 
o Jehan is available during the meeting if you want to stop the 
interview or take a break from the focus group to talk one-onone
. 
o Hand participant the statement of purpose. 
• Explain confidentiality and its limits 
o Stephanie, Jehan and Ann do not make reports to SRS 
o We ask everyone to keep the discussion private 
o We cannot guarantee everyone will keep your confidentiality 
o If you are worried that something you say will jeopardize your 
safety, well-being, a job, your housing, etc., you can either talk 
to us privately or just not bring it up. Your safety is the most 
important thing, and it is okay if you decide not to share certain 
things. 
o Hand participant the confidentiality agreement. 
• Review the discussion topics and ask if there are any safety concerns 
o Here is the list of questions we’re starting with for the group 
today. We are asking questions to improve services for people 
with disabilities who experience sexual assault or domestic 
violence. We will be talking about disability and safety and 
how agencies can be more helpful. These topics sometimes 

37 
bring up memories or feelings if something is or has happened 
in your life. In the focus group we will be focusing on how to 
improve services and we will not ask about anyone’s personal 
experiences with violence. If you are currently feeling unsafe 
because of something that is going on now or has happened in 
the past, please feel free to talk with me now. Jehan is 
available all through the meeting today and here is information 
on the local CIL and SA/DV center if something comes up after 
we’ve gone. You can always step out if the discussion becomes 
too intense or if you want to talk with us individually. Do you 
have any safety concerns that you would like to talk about now? 
o Hand participant local CIL and SA/DV contact information. 
o Hand participants the list of focus group questions. 
• Review the demographics survey and how information will be used 
o We are collecting statistics on each person who participates. 
We are doing this to make sure we have people with different 
life experiences participating in the groups. I’d like to read this 
form and then we can fill it out together or you can fill it out 
and drop it in a box after the group. Your name will not be 
attached to it. 
o Hand participant demographics form 

38 
Just ASK Needs Assessment Plan 
Appendix D.4 
People with Disabilities Focus Group Questions 
1. Can you tell us about a time you received excellent advocacy 
assistance? (follow up: from a CIL, SA/DV program, others in 
the community etc. What made the advocacy excellent?) 
2. When you think about disability, how would you describe it or 
how do you think about it? (follow up: What are some reasons 
why someone would identify with the word “disability”? What 
are some reasons why someone would not identify with the 
word “disability?”) 
3. When you think about domestic or sexual violence, how would 
you describe it or how do you think about it? (follow up: If you 
are worried that a friend may be experiencing violence, what 
are things that make you think there may be abuse? What does 
that abuse look like?) 
4. Many people have experienced domestic violence or sexual 
assault at some point in their lives. You may know someone 
who has experienced this. When someone is working with an 
advocate or service provider what makes it hard to talk about 
abuse or try to get help? (follow up: What have you seen or 
heard about? What kinds of help does someone get? How are 
they treated? What might make it easier or encourage someone 
to talk about it?) 
5. We often hear that it is hard to get help from service providers 
because they don’t seem to understand the violence or the 
disability. What would be the best way for service providers to 
help a person with a disability that has experienced sexual 
assault or domestic violence? (follow up: What do service 
providers need to do, to avoid, to do differently or to know in 
order to understand violence or disability) 

39 
6. What are some ways that people find out about services? What 
things make it easier or harder to contact and use services such 
as a CIL or an SA/DV center? Are there services that are hard 
to find or simply unavailable here in _______ (town name)? 
(What supports or services are utilized the most in your 
community?) 
7. What would ideal services, advocacy, programs look like? 
What would you tell service providers and advocates about 
providing excellent advocacy? 

40 
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) 

41 
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. 

42 
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) 
S ____________________ (date/time will be specified) 
S ____________________ (date/time will be specified) 
Individual Interview 
S ____________________ (date/time will be specified) 
S ____________________ (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): 
S Transportation 
S Child care Number of children and ages: ___________ 
S ASL interpreter 
S Other language interpreter Please specify: _______________ 
S Alternate format for materials (check one) 
S Braille 

43 
S Large print 
S Other Please specify: ____________ 
S Alternate Personal Care Attendant 
Please specify needs:____________________ 
S I will have my own Personal Care Attendant 
S Dietary concerns for snacks. Please specify:_______________ 
S Other Please specify: _______________________ 

44 
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. 

45 
Just ASK Needs Assessment Plan 
Appendix F 
Confidentiality Agreement for 
Personal Care Attendants 
Focus group participants are entitled to confidential space. I will protect the 
privacy of all participants by not sharing any information about who 
attended the group or what was said. 
__________________________________________ 
(Signature) 
__________________________________________ 
(Printed Name) 
__________________________________________ 
(Date)