City of Westland City of Westland
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City of Westland Disability Questionnaire

Please assign a number to each member living in your household and when asked by a question for the number of the people affected, write in the number you assigned to that person (Dad is #1, Mom is #2, First Sibling is #3, etc.). You may enter a household member's number for more than one question if the question applies to them, but please keep the same number for each person throughout the questionnaire.

Your Address * , Westland, MI
Your Email *
1. Does anyone in the family have SERIOUS difficulty seeing, even when wearing glasses?
Yes No     Number(s) of People Affected
2. Does anyone in the family require the use of a hearing aid?
Yes No     Number(s) of People Affected
3. Does anyone in the family have SERIOUS difficulty communicating so that PEOPLE OUTSIDE THE FAMILY understand?
Yes No     Number(s) of People Affected
4. Does anyone in the family have:
Cerebal Palsy Number(s) of People Affected
Cystic Fibrosis Number(s) of People Affected
Down Syndrome Number(s) of People Affected
Medically Determined Mental Retardation Number(s) of People Affected
Muscular Dystrophy Number(s) of People Affected
Spina Bifida Number(s) of People Affected
Autism Number(s) of People Affected
Hydrocephalus Number(s) of People Affected
5.Because of a physical or mental problem, does anyone in the family get help from another person or an outside agency in:
Bathing or Showering Number(s) of People Affected
Dressing Number(s) of People Affected
Eating Number(s) of People Affected
Getting in and out of bed or chairs Number(s) of People Affected
Using the toilet Number(s) of People Affected
Getting around inside the home Number(s) of People Affected

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