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Disability Survey
Disability Survey
To ensure that all of our residents have equal access and opportunity when coming into contact with us, it is important that we understand who has difficulty due to a disability.
We want to be certain that everyone can access the services, information, events or facilities that Yarlington Housing Group provides, by tailoring our services to those that need it.
In order for us to be able to improve how we deal with those customers with a disability, we need you to complete this form.
Please take a few moments to complete this very important survey, as the results will help us to deliver the right services to those who need them.
YOU NEED TO SUBMIT A SEPARATE FORM FOR EACH PERSON AT YOUR PROPERTY WITH A DISABILITY.
Name of person with a disability*
Unique Property Reference Number (UPRN). *
This can be found at the top of the letter relating to this survey, or on any of your rent statements.
Number of people living at this property*
Number of people at the property with a disability*
Please note the definition of a disability is ‘A physical or mental impairment which has a substantial and long- term adverse effect on a person’s ability to carry out day-to-day activities’.
Please tick if you like information on any of the following
Aids and Adaptations
Assisted Decorations
Large Print Correspondence
Does a carer live at the property
Yes
No
Does a carer visit the property daily?
Yes
No
Please tick if you receive any of the following disability benefits
Disability Living Allowance
Employment and Support Allowance
Incapacity Benefit
Invalidity Benefit
Attendance Allowance
Carer's Allowance
Constant Attendance Allowance
Do you have a physical disability?
Yes
No
If yes, what type of physical disability do you have?
Please tick if you have one of the following sensory disabilities:
Blindness
Partial Sight
Hearing Difficulties
Do you have a mental health condition?
Yes
No
If yes, what type of mental health condition do you have?
Do you have any learning difficulties?
Yes
No
Do you have any longstanding illness or health condition (for example Cancer, Chronic Heart Disease or Epilepsy?)
Yes
No
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