DB101 California - First-Time User Survey

Print This Page

Return to Site

Disability Benefits 101: Working with a disability in California

First-Time User Survey

If you're new to Disability Benefits 101, we ask that you please fill in the short Pre-Use Survey below. The results of this important survey will help us make the site better.

Your responses are completely anonymous. You will not be asked for any information that might identify you, and your responses will be confidential. No individual results will be shared with any government agency or other organization.

We won't send you anything as a result of your filling out this form. If you need help, visit our Forums or use our Feedback form.

Your help is greatly appreciated!

I am seeking information about disability benefits for:
(Select only one response)

Myself
Relative or friend
Client at an organization where I work or volunteer
Other (please specify)

I am interested in information about the following:
(Check all that apply)

The 250% California Working Disabled Program (Medi-Cal for working persons)
Medi-Cal
Medicare
Health benefit protections (COBRA, OBRA, Cal-COBRA, HIPAA, AB1672)
Private health coverage
Public disability income programs (SDI, SSI, SSDI, CAPI - Cash Assistance Program for Immigrants)
Private disability income (short and long term disability insurance)
Ticket to Work Program or other employment support/services
Prescription drug coverage (Patient Assistance Programs, SB 393, AIDS Drug Assistance Program, Medicare Part D)
Plan for Achieving Self-Support (PASS)
Scholastic aid (Pell Grants)
CalWORKs
Tax Credits (Earned Income Tax Credit, Work Opportunity Tax Credit)
Workplace personal assistance (PAS, IHSS)
Working, or the effect of work on disability benefits
Other programs (please specify)

Please rate your knowledge of the following programs and services by using the scale below:
(Select only one response for each statement)

Very Low	Low	Moderate	High	Very High
					General knowledge of disability benefit programs
					The 250% California Working Disabled Program (Medi-Cal for working persons)
					Medi-Cal
					Medicare
					Health benefit protections (COBRA, OBRA, Cal-COBRA, HIPAA, AB1672)
					Private health coverage
					Public disability income programs (SDI, SSI, SSDI, CAPI - Cash Assistance Program for Immigrants)
					Private disability income (short and long term disability insurance)
					Ticket to Work Program or other employment support/services
					Prescription drug coverage (Patient Assistance Programs, SB 393, AIDS Drug Assistance Program, Medicare Part D)
					Plan for Achieving Self-Support (PASS)
					Scholastic aid (Pell Grants)
					CalWORKs
					Tax Credits (Earned Income Tax Credit, Work Opportunity Tax Credit)
					Workplace personal assistance (PAS, IHSS)
					Knowledge of how working affects disability benefits

Please use the scale below to indicate how the following statements apply to the individual with a disability (self, family member, friend, or a client at an organization where you work or volunteer).
(Select only one response for each statement)

Strongly Disagree	Disagree	Agree	Strongly Agree
				I am currently interested in changing my work status (becoming employed or changing employment)
				Information about disability health and income benefits will influence my decisions about becoming employed or changing employment

http://www.disabilitybenefits101.org/firsttime.aspx