MUHSEN UK Needs Assessment Form
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Email
example@example.com
Phone Number
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Individual Information
I am a
Parent/Guardian or Caregiver
Individual with Special Needs
Other
Name
First Name
Last Name
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Information of Individual with Special Needs
Name
First Name
Last Name
Age
birth-5
6-12
13-17
18-24
25-39
40+
Gender
Male
Female
Prefer not to say
Address
City
Post Code
Country
Diagnosis (select all that apply)
Attention-Deficit/Hyperactivity Disorder
Blindness
Deafness
Down Syndrome
Hearing Impairment (Hard of Hearing)
Muscular Dystrophy
Speech Impairment
Autism
Cerebral Palsy
Developmental Delay
Epilepsy
Learning Disability
Physical Disability
Other
School Placement (select all that apply)
Primary School
Secondary School
Nursery
Homeschool
Islamic School/Madrasa
College/University
Special Needs School
Adult Program
Does not apply
Other
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Survey Questions
Name of your local masjid
City
Country
On a scale of 1 to 10, how would you rate your family member's acceptance in the Muslim community? (1 being the least accepted, 10 being the most accepted)
1
2
3
4
5
6
7
8
9
10
Which supports would enhance participation from your Special Needs family member at the Masjid? (select all that apply)
Adult Life Skills Programs
Accessibility
Access to Programs and Classes
Braille Quran
Child Care Options
Closed Captioning/Visual Resources
Large Print Quran
Open House for families with Special Needs
Quiet Room
Sensory Supports (Light & Sound)
Sign Language
Support Groups
Weekend Schools
Youth Options
Other
Would you and/or your Special Needs family member like to attend a gathering to meet other families?
Yes
No
Maybe
Would you be interested in a caregiver/individual/sibling support group?
Yes
No
Maybe
Would you be interested in volunteering to help with MUHSEN's mission?
Yes
No
Maybe
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